Healthcare Provider Details

I. General information

NPI: 1609263052
Provider Name (Legal Business Name): STEPHAN IDRIS MAMBAZO MSW, LICSW-PIP, CGRS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2015
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 TAYLOR OAKS CIR UNIT 104
MONTGOMERY AL
36116-8538
US

IV. Provider business mailing address

PO BOX 230155
MONTGOMERY AL
36123-0155
US

V. Phone/Fax

Practice location:
  • Phone: 844-626-2296
  • Fax: 855-461-3448
Mailing address:
  • Phone: 844-626-2296
  • Fax: 855-461-3448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW009851L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3796C
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberTPSW1856
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberQ1-0013037
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: