Provider Demographics
NPI:1760015192
Name:DZENGA, CHAIDAMOYO GOODSON
Entity Type:Individual
Prefix:
First Name:CHAIDAMOYO
Middle Name:GOODSON
Last Name:DZENGA
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 1:1216 CAROLINA AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-6564
Mailing Address - Country:US
Mailing Address - Phone:412-886-8245
Mailing Address - Fax:
Practice Address - Street 1:1216 CAROLINA AVE APT 3
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-6564
Practice Address - Country:US
Practice Address - Phone:412-886-8245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician