Provider Demographics
NPI:1124736293
Name:FOMIN, ANGELA FERRAZ
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:FERRAZ
Last Name:FOMIN
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 1:79 PARIS ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02128-3053
Mailing Address - Country:US
Mailing Address - Phone:617-676-5759
Mailing Address - Fax:
Practice Address - Street 1:79 PARIS ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02128-3053
Practice Address - Country:US
Practice Address - Phone:617-568-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-08
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty