Healthcare Provider Details

I. General information

NPI: 1720934458
Provider Name (Legal Business Name): TAMAR GOUSSE
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2026
Last Update Date: 03/05/2026
Certification Date: 03/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 WILBERT RD
DORCHESTER CENTER MA
02124-1447
US

IV. Provider business mailing address

30 WILBERT RD
BOSTON MA
02124-1447
US

V. Phone/Fax

Practice location:
  • Phone: 617-318-5597
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: