Provider Demographics
NPI:1710644752
Name:KAMBASHA, KUMBIRAI
Entity Type:Individual
Prefix:
First Name:KUMBIRAI
Middle Name:
Last Name:KAMBASHA
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 1:4710 W SAGINAW HWY STE 1
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-2654
Mailing Address - Country:US
Mailing Address - Phone:517-927-3452
Mailing Address - Fax:
Practice Address - Street 1:4710 W SAGINAW HWY STE 1
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-2654
Practice Address - Country:US
Practice Address - Phone:517-927-3452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-24
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451021949101YM0800X, 101YP2500X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional