Provider Demographics
NPI:1679027163
Name:MBOMA, WILLY
Entity Type:Individual
Prefix:
First Name:WILLY
Middle Name:
Last Name:MBOMA
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 1:340 MAIN ST STE 802
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608-1606
Mailing Address - Country:US
Mailing Address - Phone:508-756-7557
Mailing Address - Fax:
Practice Address - Street 1:340 MAIN ST STE 802
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1606
Practice Address - Country:US
Practice Address - Phone:508-756-7557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-12
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker