Stephan Idris Mambazo, MSW, LICSW-PIP, CGRS

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

3796C Issued in AL

Practice address

2541 College St
Montgomery, AL 36106-2124

Phone

(334) 207-7657

NPI assigned

Apr 23, 2015

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Intellectualsoul Clinical Consulting, LLC

  • Community/Behavioral Health Agency
  • Montgomery, AL
  • NPI 1912559675
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1429747200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1488326400000",
    "number": "1609263052",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2541 COLLEGE ST",
            "city": "MONTGOMERY",
            "state": "AL",
            "postal_code": "361062124",
            "telephone_number": "334-207-7657"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2541 COLLEGE ST",
            "city": "MONTGOMERY",
            "state": "AL",
            "postal_code": "361062124",
            "telephone_number": "334-207-7657"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MAMBAZO",
        "first_name": "STEPHAN",
        "middle_name": "IDRIS",
        "credential": "MSW, LICSW-PIP, CGRS",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2015-04-23",
        "last_updated": "2017-03-01",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "AL",
            "license": "3796C",
            "primary": true
        },
        {
            "code": "104100000X",
            "taxonomy_group": "",
            "desc": "Social Worker",
            "state": "PA",
            "license": "SW009851L",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Arthur Mallory, LICSW
• Deborah L. Mallory, CRNA
• Thomas A. Mallory, CRNA
• Calyn Ashley Malloy, RN, MSN, FNP-C
• Margaret Doreen Maloney, MD
• Maryanna Elizabeth Manderville, LPC
• Joseph Anthony Mangini, M.D.
• Robbie Mangum, M.S.,NCC,LPC
• Ashley Cannon Mann, CRNP
• Clint D Mann, DPT

• Clinical Social Worker in Montgomery, AL
• Providers in Montgomery, AL by specialty
• Clinical Social Worker in Alabama

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 1, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.