Provider Demographics
NPI:1063780997
Name:KOROMA, DUSUBA MMAH (MA)
Entity type:Individual
Prefix:MRS
First Name:DUSUBA
Middle Name:MMAH
Last Name:KOROMA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:17 DAWN AVE
Mailing Address - Street 2:
Mailing Address - City:MERRIMACK
Mailing Address - State:NH
Mailing Address - Zip Code:03054-4253
Mailing Address - Country:US
Mailing Address - Phone:603-579-9916
Mailing Address - Fax:
Practice Address - Street 1:170 MAIN ST # G4-G8
Practice Address - Street 2:
Practice Address - City:TEWKSBURY
Practice Address - State:MA
Practice Address - Zip Code:01876-1765
Practice Address - Country:US
Practice Address - Phone:781-348-9041
Practice Address - Fax:978-455-0274
Is Sole Proprietor?:No
Enumeration Date:2011-12-06
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA13060101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)