Provider Demographics
NPI:1215414750
Name:NZURIWATU, MWANZA
Entity Type:Individual
Prefix:
First Name:MWANZA
Middle Name:
Last Name:NZURIWATU
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 1:103 COMMERCIAL ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-3101
Mailing Address - Country:US
Mailing Address - Phone:508-580-4691
Mailing Address - Fax:
Practice Address - Street 1:103 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-3101
Practice Address - Country:US
Practice Address - Phone:508-580-4691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-27
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1Medicaid
MA1Medicaid