Provider Demographics
NPI:1538838651
Name:MLONGECHA, IBOCWA PHILLIP
Entity type:Individual
Prefix:
First Name:IBOCWA
Middle Name:PHILLIP
Last Name:MLONGECHA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 ELIOT RD
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-5419
Mailing Address - Country:US
Mailing Address - Phone:857-505-8524
Mailing Address - Fax:
Practice Address - Street 1:400 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-4729
Practice Address - Country:US
Practice Address - Phone:781-843-3853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-10
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty