Provider Demographics
NPI:1083107668
Name:NANKUNDA, OCTAVIA
Entity Type:Individual
Prefix:
First Name:OCTAVIA
Middle Name:
Last Name:NANKUNDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 WOODCOCK AVE APT 8
Mailing Address - Street 2:
Mailing Address - City:HAVERHILL
Mailing Address - State:MA
Mailing Address - Zip Code:01832-3877
Mailing Address - Country:US
Mailing Address - Phone:717-802-1180
Mailing Address - Fax:
Practice Address - Street 1:26 PARKRIDGE RD STE 2B
Practice Address - Street 2:
Practice Address - City:HAVERHILL
Practice Address - State:MA
Practice Address - Zip Code:01835-8515
Practice Address - Country:US
Practice Address - Phone:717-802-1180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-08
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health