Provider Demographics
NPI:1700134715
Name:ANDERSON, NABUCHI GRACE (MHC)
Entity Type:Individual
Prefix:MRS
First Name:NABUCHI
Middle Name:GRACE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MHC
Other - Prefix:MRS
Other - First Name:NABUCHI
Other - Middle Name:GRACE
Other - Last Name:MASONGEZI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:REGISTERED MHC
Mailing Address - Street 1:PO BOX 444
Mailing Address - Street 2:
Mailing Address - City:MASCOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:34753-0444
Mailing Address - Country:US
Mailing Address - Phone:352-255-6458
Mailing Address - Fax:352-410-6118
Practice Address - Street 1:15508 WILLET CT
Practice Address - Street 2:
Practice Address - City:MASCOTTE
Practice Address - State:FL
Practice Address - Zip Code:34753-9102
Practice Address - Country:US
Practice Address - Phone:352-255-6458
Practice Address - Fax:352-410-6118
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-22
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X, 171M00000X
FLIMH 11052101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004444701Medicaid
FL004444700Medicaid