Provider Demographics
NPI:1508251984
Name:MASUKU, SANELISO
Entity Type:Individual
Prefix:
First Name:SANELISO
Middle Name:
Last Name:MASUKU
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 1:43 GARRISON RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-4445
Mailing Address - Country:US
Mailing Address - Phone:617-277-8107
Mailing Address - Fax:617-734-6385
Practice Address - Street 1:43 GARRISON RD
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-4445
Practice Address - Country:US
Practice Address - Phone:617-277-8107
Practice Address - Fax:617-734-6385
Is Sole Proprietor?:No
Enumeration Date:2015-04-01
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA2797892084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program