=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851162085
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEWGENN PSYCHIATRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2024
-----------------------------------------------------
Last Update Date | 01/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 303 WYMAN ST STE 300
-----------------------------------------------------
City | WALTHAM
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02451-1255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 774-364-8183
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 303 WYMAN ST STE 300
-----------------------------------------------------
City | WALTHAM
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02451-1255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CNP
-----------------------------------------------------
Name | ALBERTA KOOSONO ADU
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 774-364-8183
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------