=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154128569
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RACHAEL MBOGA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2025
-----------------------------------------------------
Last Update Date | 02/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7208 DOBSON ST
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46268-2128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-654-6806
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9346 KUNGSHOLM DR APT B
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46250-1144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 463-294-1373
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number | RBT-24-33749
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------