Provider Demographics
NPI:1912886318
Name:IMADOMWONYI, GLADYS
Entity type:Individual
Prefix:MS
First Name:GLADYS
Middle Name:
Last Name:IMADOMWONYI
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 1:590 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-2582
Mailing Address - Country:US
Mailing Address - Phone:617-894-8732
Mailing Address - Fax:
Practice Address - Street 1:590 CENTRE ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-2582
Practice Address - Country:US
Practice Address - Phone:617-894-8732
Practice Address - Fax:617-894-8732
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-29
Last Update Date:2025-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18113225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist