Provider Demographics
NPI:1720439961
Name:GANAGO, TOATE
Entity Type:Individual
Prefix:
First Name:TOATE
Middle Name:
Last Name:GANAGO
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 1:6781 S AQUILINE DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85756-8639
Mailing Address - Country:US
Mailing Address - Phone:520-319-0778
Mailing Address - Fax:520-296-8244
Practice Address - Street 1:6781 S AQUILINE DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85756-8639
Practice Address - Country:US
Practice Address - Phone:520-319-0778
Practice Address - Fax:520-296-8244
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-29
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH4917320800000X, 385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH4917OtherAZ DHS LICENSE