Provider Demographics
NPI:1457127003
Name:MUTAYOMBA, IRENE MARVIS (DIRECT CARE WORKER)
Entity Type:Individual
Prefix:MRS
First Name:IRENE
Middle Name:MARVIS
Last Name:MUTAYOMBA
Suffix:
Gender:F
Credentials:DIRECT CARE WORKER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 CLARK RD
Mailing Address - Street 2:
Mailing Address - City:SHIRLEY
Mailing Address - State:MA
Mailing Address - Zip Code:01464-2632
Mailing Address - Country:US
Mailing Address - Phone:978-998-5144
Mailing Address - Fax:
Practice Address - Street 1:139 CLARK RD
Practice Address - Street 2:
Practice Address - City:SHIRLEY
Practice Address - State:MA
Practice Address - Zip Code:01464-2632
Practice Address - Country:US
Practice Address - Phone:978-998-5144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health