Provider Demographics
NPI:1811689268
Name:LWANGA, TIM DEVIN
Entity type:Individual
Prefix:MR
First Name:TIM
Middle Name:DEVIN
Last Name:LWANGA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3620 MYSTIC VALLEY PKWY APT E315
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-5755
Mailing Address - Country:US
Mailing Address - Phone:781-502-1016
Mailing Address - Fax:
Practice Address - Street 1:3620 MYSTIC VALLEY PKWY APT E315
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-5755
Practice Address - Country:US
Practice Address - Phone:781-502-1016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health