Provider Demographics
NPI:1326611013
Name:MUGABEKAZI, ANGELIQUE
Entity Type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:
Last Name:MUGABEKAZI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3153 RIVERVIEW DR NW APT 1B
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49544-8537
Mailing Address - Country:US
Mailing Address - Phone:616-304-2862
Mailing Address - Fax:
Practice Address - Street 1:233 FULTON ST E
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-3200
Practice Address - Country:US
Practice Address - Phone:616-490-3468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-20
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty