Provider Demographics
NPI:1770626707
Name:MUTAMBA, MASIMBA MAXWELL (BS)
Entity type:Individual
Prefix:MR
First Name:MASIMBA
Middle Name:MAXWELL
Last Name:MUTAMBA
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:945 CLEVLAND ST
Mailing Address - Street 2:APT. B-14
Mailing Address - City:PULASKI
Mailing Address - State:TN
Mailing Address - Zip Code:38478-4442
Mailing Address - Country:US
Mailing Address - Phone:336-509-3971
Mailing Address - Fax:931-560-4221
Practice Address - Street 1:115 DYER ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-4551
Practice Address - Country:US
Practice Address - Phone:931-560-4236
Practice Address - Fax:931-560-4221
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health