Healthcare Provider Details

I. General information

NPI: 1669279899
Provider Name (Legal Business Name): OGHOGHO JOYCE IDUMWONYI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2025
Last Update Date: 02/26/2025
Certification Date: 02/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

186 MASSACHUSETTS AVE
BOSTON MA
02115-3011
US

IV. Provider business mailing address

186 MASSACHUSETTS AVE
BOSTON MA
02115-3011
US

V. Phone/Fax

Practice location:
  • Phone: 617-487-2211
  • Fax: 617-830-9466
Mailing address:
  • Phone: 617-487-2211
  • Fax: 617-830-9466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: