Healthcare Provider Details

I. General information

NPI: 1902280985
Provider Name (Legal Business Name): MONA ITANI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2015
Last Update Date: 08/07/2020
Certification Date: 08/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BOSTON MEDICAL CENTER PLACE
BOSTON MA
02118
US

IV. Provider business mailing address

801 ALBANY ST. FLOOR GROUND
BOSTON MA
02119
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-5245
  • Fax: 617-414-5520
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number277868
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number277868
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: