Provider Demographics
NPI:1639730856
Name:CHIBANGA, TATENDA (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:TATENDA
Middle Name:
Last Name:CHIBANGA
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 CHAMISAL RD NW
Mailing Address - Street 2:
Mailing Address - City:LOS RANCHOS
Mailing Address - State:NM
Mailing Address - Zip Code:87107-6408
Mailing Address - Country:US
Mailing Address - Phone:505-720-9049
Mailing Address - Fax:
Practice Address - Street 1:808 CHAMISAL RD NW
Practice Address - Street 2:
Practice Address - City:LOS RANCHOS
Practice Address - State:NM
Practice Address - Zip Code:87107-6408
Practice Address - Country:US
Practice Address - Phone:505-720-9049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-27
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPT5500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist