MEDICARE: GRACE BASONGA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320800000X	Mental Illness Community Based Residential Treatment Facility	ADBH20002	AZ
2	385H00000X	Respite Care	ADBH20002	AZ

General Provider Information

NPI Number	:	1639059256
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACE BASONGA

Provider Business Mailing Address
First Line	:	4000 N CENTRAL AVE STE 100
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85012-3520
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6593 W CEDAR BRANCH WAY
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85757-1514
Country	:	US
Telephone Number	:	520-312-2289
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/04/2025
Last Update Date	:	10/24/2025

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Directions to “ GRACE BASONGA ” Practice Location

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