Healthcare Provider Details

I. General information

NPI: 1730099003
Provider Name (Legal Business Name): IRIS BROKAW PSYCHIATRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

769 CENTRE ST
JAMAICA PLAIN MA
02130-2557
US

IV. Provider business mailing address

148 BLAKE ST
HYDE PARK MA
02136-6137
US

V. Phone/Fax

Practice location:
  • Phone: 617-506-3565
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SHANTELLE D BROKAW
Title or Position: NP
Credential:
Phone: 617-506-3565