Provider Demographics
NPI:1376250548
Name:KARGBO, ABDUL
Entity Type:Individual
Prefix:
First Name:ABDUL
Middle Name:
Last Name:KARGBO
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 1:3707 E SOUTHERN AVE STE 1035
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-6203
Mailing Address - Country:US
Mailing Address - Phone:919-247-2378
Mailing Address - Fax:
Practice Address - Street 1:3707 E SOUTHERN AVE STE 1035
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-6203
Practice Address - Country:US
Practice Address - Phone:919-247-2378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-27
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 174H00000X
NC313410163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No174H00000XOther Service ProvidersHealth Educator