Healthcare Provider Details

I. General information

NPI: 1639090012
Provider Name (Legal Business Name): HERVE MUDAHAKANA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7108 S KANNER HWY
STUART FL
34997-7462
US

IV. Provider business mailing address

24 TAYLOR ST APT C2
SPRINGFIELD MA
01103-1245
US

V. Phone/Fax

Practice location:
  • Phone: 185-583-2672
  • Fax:
Mailing address:
  • Phone: 267-333-4291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: