Basic Information
| Provider Information | |||||||||
| NPI: | 1790259695 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ONDIMU | ||||||||
| FirstName: | KENNEDY | ||||||||
| MiddleName: | AMINGA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 ROBYN LN | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020481689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7813085174 | ||||||||
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| Practice Location | |||||||||
| Address1: | 109 OAK ST STE 103 | ||||||||
| Address2: | |||||||||
| City: | NEWTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024641493 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176585611 | ||||||||
| FaxNumber: | 6176636000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2019 | ||||||||
| LastUpdateDate: | 01/14/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | MA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.