Healthcare Provider Details

I. General information

NPI: 1326859869
Provider Name (Legal Business Name): CHINWIKE OKOLI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2025
Last Update Date: 01/15/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 CENTRE ST
JAMAICA PLAIN MA
02130-3445
US

IV. Provider business mailing address

790 SALEM ST
MALDEN MA
02148-4415
US

V. Phone/Fax

Practice location:
  • Phone: 857-283-4768
  • Fax:
Mailing address:
  • Phone: 781-627-6654
  • Fax:

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: