Provider Demographics
NPI:1447772264
Name:KABAMBA, BOB (SKA-SHIFRA HOME)
Entity Type:Individual
Prefix:
First Name:BOB
Middle Name:
Last Name:KABAMBA
Suffix:
Gender:M
Credentials:SKA-SHIFRA HOME
Other - Prefix:
Other - First Name:SKA
Other - Middle Name:
Other - Last Name:SHIFRA HOME
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:SKA-SHIFRA HOME
Mailing Address - Street 1:7136 N 73RD DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85303-2569
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7136 N 73RD DR
Practice Address - Street 2:
Practice Address - City:GENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85303
Practice Address - Country:US
Practice Address - Phone:623-435-3976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-13
Last Update Date:2017-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician