Provider Demographics
NPI:1720833866
Name:UTIN, MFONOBONG
Entity Type:Individual
Prefix:
First Name:MFONOBONG
Middle Name:
Last Name:UTIN
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 1:905 PEBBLESTONE DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-7194
Mailing Address - Country:US
Mailing Address - Phone:336-327-3810
Mailing Address - Fax:
Practice Address - Street 1:8117 EBENEZER CHURCH RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-7307
Practice Address - Country:US
Practice Address - Phone:888-329-4535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-22
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1720833866106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty