Individual
IBIAM IBIAM ARU
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
1109 RIVER ST, HYDE PARK, MA 02136-2914
(781) 308-8149
Mailing address
1109 RIVER ST, HYDE PARK, MA 02136-2914
Taxonomy
Speciality
Code
Description
License number
State
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
RN2386159
MA
Other
Enumeration date
06/05/2026
Last updated
06/05/2026
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