Provider Demographics
NPI:1396234357
Name:BAZENGA BISELELE, GRACIA
Entity type:Individual
Prefix:
First Name:GRACIA
Middle Name:
Last Name:BAZENGA BISELELE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3295 PIERREMONT RD
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89503-1936
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3295 PIERREMONT RD
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-1936
Practice Address - Country:US
Practice Address - Phone:775-225-0388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-05
Last Update Date:2018-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health