Provider Demographics
NPI:1184476889
Name:WAMBAIRE, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WAMBAIRE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6652 E CALLE HERCULO
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-5622
Mailing Address - Country:US
Mailing Address - Phone:520-248-1919
Mailing Address - Fax:520-745-5361
Practice Address - Street 1:6652 E CALLE HERCULO
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-5622
Practice Address - Country:US
Practice Address - Phone:520-248-1919
Practice Address - Fax:520-745-5361
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-04
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH9519324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility