Basic Information
| Provider Information | |||||||||
| NPI: | 1679008619 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | UKUEBERUWA O'SHEA | ||||||||
| FirstName: | DEDE | ||||||||
| MiddleName: | |||||||||
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| Credential: | PH.D. | ||||||||
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| OtherLastName: | UKUEBERUWA | ||||||||
| OtherFirstName: | DEDE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1 GUSTAVE L LEVY PL # 1163 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100296504 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 41 MALL RD | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018056501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817448085 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2017 | ||||||||
| LastUpdateDate: | 10/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 023075 | NY | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 30347 | CA | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 103TC0700X | 11385 | MA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.