Provider Demographics
NPI:1801390059
Name:HAQUE, TAMANNA TASNIM
Entity Type:Individual
Prefix:
First Name:TAMANNA
Middle Name:TASNIM
Last Name:HAQUE
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 1:3 DARLING ST APT 9
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02120-2845
Mailing Address - Country:US
Mailing Address - Phone:631-987-4328
Mailing Address - Fax:
Practice Address - Street 1:109 PETERBOROUGH ST APT 24
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-4225
Practice Address - Country:US
Practice Address - Phone:631-987-4328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-22
Last Update Date:2020-07-13
Deactivation Date:2020-07-01
Deactivation Code:
Reactivation Date:2020-07-08
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician