Basic Information
| Provider Information | |||||||||
| NPI: | 1316023245 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAMBA | ||||||||
| FirstName: | ANNE MARIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WAVEZWA | ||||||||
| OtherFirstName: | ANNE MARIE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 203 LEWIS ST | ||||||||
| Address2: | APT#1 | ||||||||
| City: | LYNN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019024863 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7815994287 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 55 DIMOCK ST | ||||||||
| Address2: | COMMUNITY CARE CENTER | ||||||||
| City: | ROXBURY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021191029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174428800 | ||||||||
| FaxNumber: | 6174421702 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 931 | MA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.