Provider Demographics
NPI:1992499776
Name:MUGABO, BEN
Entity type:Individual
Prefix:
First Name:BEN
Middle Name:
Last Name:MUGABO
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 1:1933 E BRILL ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-3020
Mailing Address - Country:US
Mailing Address - Phone:773-312-2637
Mailing Address - Fax:
Practice Address - Street 1:1933 E BRILL ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-3020
Practice Address - Country:US
Practice Address - Phone:773-312-2637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-06
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician