Healthcare Provider Details

I. General information

NPI: 1023941234
Provider Name (Legal Business Name): IBIAM IBIAM ARU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2026
Last Update Date: 06/05/2026
Certification Date: 05/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1109 RIVER ST
HYDE PARK MA
02136-2914
US

IV. Provider business mailing address

1109 RIVER ST
HYDE PARK MA
02136-2914
US

V. Phone/Fax

Practice location:
  • Phone: 781-308-8149
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN2386159
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: