Provider Demographics
NPI:1417270133
Name:ONUNGWE, MARY O (LAC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:O
Last Name:ONUNGWE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 WAYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-4314
Mailing Address - Country:US
Mailing Address - Phone:401-331-4250
Mailing Address - Fax:
Practice Address - Street 1:99 WAYLAND AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-4314
Practice Address - Country:US
Practice Address - Phone:401-331-4250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-09
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1611101YA0400X
RICDP00800101YA0400X
RICDS00096101YA0400X
RIMHC01092101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)