Provider Demographics
NPI:1679952980
Name:MITCHELL, OKERA MOMAR
Entity Type:Individual
Prefix:MR
First Name:OKERA
Middle Name:MOMAR
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:OKERA
Other - Middle Name:MOMAR
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MM
Mailing Address - Street 1:20 MAYWOOD ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02119-2182
Mailing Address - Country:US
Mailing Address - Phone:857-417-7875
Mailing Address - Fax:
Practice Address - Street 1:20 MAYWOOD ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02119-2182
Practice Address - Country:US
Practice Address - Phone:857-417-7875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-20
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS776979101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health