Provider Demographics
NPI:1972090603
Name:MOSTAFA, FATEMA
Entity type:Individual
Prefix:
First Name:FATEMA
Middle Name:
Last Name:MOSTAFA
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 1:60D ROBERT FORD RD
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-3011
Mailing Address - Country:US
Mailing Address - Phone:617-415-6104
Mailing Address - Fax:
Practice Address - Street 1:60D ROBERT FORD RD
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-3011
Practice Address - Country:US
Practice Address - Phone:617-415-6104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-18
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician