Provider Demographics
NPI:1407193998
Name:KYAGAMBIDDWA, TONNY MAKUMBI
Entity Type:Individual
Prefix:
First Name:TONNY MAKUMBI
Middle Name:
Last Name:KYAGAMBIDDWA
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 1:520 DUDLEY STREET, ROXBURY
Mailing Address - Street 2:
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02119-2206
Mailing Address - Country:US
Mailing Address - Phone:617-989-9499
Mailing Address - Fax:
Practice Address - Street 1:520 DUDLEY ST
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-2769
Practice Address - Country:US
Practice Address - Phone:617-989-9499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-03
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor