Provider Demographics
NPI:1093586679
Name:WANJIRU, SAMUEL
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:WANJIRU
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 1:216 W BOYLSTON ST STE 200
Mailing Address - Street 2:
Mailing Address - City:WEST BOYLSTON
Mailing Address - State:MA
Mailing Address - Zip Code:01583-1788
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:216 W BOYLSTON ST STE 200
Practice Address - Street 2:
Practice Address - City:WEST BOYLSTON
Practice Address - State:MA
Practice Address - Zip Code:01583-1788
Practice Address - Country:US
Practice Address - Phone:508-213-3355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-11
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician