Provider Demographics
NPI:1609263052
Name:MAMBAZO, STEPHAN IDRIS (MSW, LICSW-PIP, CGRS)
Entity Type:Individual
Prefix:
First Name:STEPHAN
Middle Name:IDRIS
Last Name:MAMBAZO
Suffix:
Gender:M
Credentials:MSW, LICSW-PIP, CGRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2541 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-2124
Mailing Address - Country:US
Mailing Address - Phone:334-207-7657
Mailing Address - Fax:
Practice Address - Street 1:2541 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-2124
Practice Address - Country:US
Practice Address - Phone:334-207-7657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-23
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3796C1041C0700X
PASW009851L104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker