Healthcare Provider Details

I. General information

NPI: 1053135087
Provider Name (Legal Business Name): IAN GEREK IWANICKI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2024
Last Update Date: 11/15/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

867 BOYLSTON STREET 5TH FLOOR #2050
BOSTON MA
02116
US

IV. Provider business mailing address

867 BOYLSTON STREET 5TH FLOOR #2050
BOSTON MA
02116
US

V. Phone/Fax

Practice location:
  • Phone: 617-356-7787
  • Fax: 857-264-5776
Mailing address:
  • Phone: 617-356-7787
  • Fax: 857-264-5776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: