Provider Demographics
NPI:1053174920
Name:HAKIZIMANA, JOHN BOB
Entity type:Individual
Prefix:
First Name:JOHN BOB
Middle Name:
Last Name:HAKIZIMANA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3235 WHITE OAK DR APT 12
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45420-1564
Mailing Address - Country:US
Mailing Address - Phone:937-245-0815
Mailing Address - Fax:
Practice Address - Street 1:3235 WHITE OAK DR APT 12
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45420-1564
Practice Address - Country:US
Practice Address - Phone:937-245-0815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-02
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHUY742147103TA0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging