=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881465771
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PEARL JANEPHER MUGISHA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2024
-----------------------------------------------------
Last Update Date | 01/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2034 E SOUTHERN AVE STE U
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85282-7519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-905-1164
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7663 W FLYNN LN
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85303-2941
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-905-1164
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | CSLG13087
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------