Healthcare Provider Details

I. General information

NPI: 1124823794
Provider Name (Legal Business Name): BAHATI BAKANGA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2025
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23835 W HIDALGO AVE
BUCKEYE AZ
85326-7008
US

IV. Provider business mailing address

4000 N CENTRAL AVE STE 100
PHOENIX AZ
85012-3520
US

V. Phone/Fax

Practice location:
  • Phone: 702-465-7946
  • Fax:
Mailing address:
  • Phone: 602-859-7794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberBH10421
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License NumberBH10421
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: