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:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH4917320800000X, 385H00000X, 171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH4917OtherAZ DHS LICENSE