Provider Demographics
NPI:1700601416
Name:EMMANUEL, IRENE
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:EMMANUEL
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 1:186 MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-3011
Mailing Address - Country:US
Mailing Address - Phone:617-864-8140
Mailing Address - Fax:617-864-2541
Practice Address - Street 1:186 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-3011
Practice Address - Country:US
Practice Address - Phone:617-864-8140
Practice Address - Fax:617-864-2541
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-18
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA171M00000X171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator