Provider Demographics
NPI:1558190025
Name:KWANGABA, IRENE IMANI (OTD)
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:IMANI
Last Name:KWANGABA
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 W 17TH ST
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85281-6415
Mailing Address - Country:US
Mailing Address - Phone:760-412-9862
Mailing Address - Fax:
Practice Address - Street 1:3700 N 24TH ST STE 130
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-6535
Practice Address - Country:US
Practice Address - Phone:602-903-4072
Practice Address - Fax:866-877-7902
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-31
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist