Provider Demographics
NPI:1376988352
Name:OCTAVIUS, ASTRUDE D (MASTERS)
Entity Type:Individual
Prefix:
First Name:ASTRUDE
Middle Name:D
Last Name:OCTAVIUS
Suffix:
Gender:F
Credentials:MASTERS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-5924
Mailing Address - Country:US
Mailing Address - Phone:781-861-0890
Mailing Address - Fax:
Practice Address - Street 1:730 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-5924
Practice Address - Country:US
Practice Address - Phone:781-861-0890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-06
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIGH57134Medicaid