Healthcare Provider Details

I. General information

NPI: 1255165700
Provider Name (Legal Business Name): MUTOBA BUKASA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 CHERRY ST
TOLEDO OH
43608-2906
US

IV. Provider business mailing address

1425 STARR AVE
TOLEDO OH
43605-2456
US

V. Phone/Fax

Practice location:
  • Phone: 419-724-3133
  • Fax: 419-936-7606
Mailing address:
  • Phone: 419-936-7600
  • Fax: 419-936-7606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: