Provider Demographics
NPI:1518159755
Name:WAMBAA, JOAN WACEKE (MPT)
Entity Type:Individual
Prefix:MS
First Name:JOAN
Middle Name:WACEKE
Last Name:WAMBAA
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:JOANNE
Other - Middle Name:WACEKE
Other - Last Name:WAMBAA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MPT
Mailing Address - Street 1:193 STRATHMORE RD
Mailing Address - Street 2:5
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-5212
Mailing Address - Country:US
Mailing Address - Phone:423-612-3416
Mailing Address - Fax:
Practice Address - Street 1:75 FRANCIS ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6110
Practice Address - Country:US
Practice Address - Phone:617-732-6853
Practice Address - Fax:617-277-1078
Is Sole Proprietor?:No
Enumeration Date:2007-08-13
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA17745225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist