Provider Demographics
NPI:1366256265
Name:KOUELA, RAOGO DAMAS
Entity type:Individual
Prefix:
First Name:RAOGO
Middle Name:DAMAS
Last Name:KOUELA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2341 N 92ND CT
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68134-5853
Mailing Address - Country:US
Mailing Address - Phone:402-880-2210
Mailing Address - Fax:
Practice Address - Street 1:2341 N 92ND CT
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68134-5853
Practice Address - Country:US
Practice Address - Phone:402-880-2210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-03
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health