Provider Demographics
NPI:1760222798
Name:MAURIDI, MTUKUFU (HEALTHCARE PROVIDER)
Entity type:Individual
Prefix:
First Name:MTUKUFU
Middle Name:
Last Name:MAURIDI
Suffix:
Gender:M
Credentials:HEALTHCARE PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6402 W AVALON DRIVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85033
Mailing Address - Country:US
Mailing Address - Phone:602-635-8209
Mailing Address - Fax:
Practice Address - Street 1:6402 W AVALON DRIVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85033
Practice Address - Country:US
Practice Address - Phone:602-635-8209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-28
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH9180106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician