Basic Information
| Provider Information | |||||||||
| NPI: | 1912942202 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OMOAYO | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 W CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023017501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085804691 | ||||||||
| FaxNumber: | 5085805162 | ||||||||
| Practice Location | |||||||||
| Address1: | 1115 W CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023017501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5082234691 | ||||||||
| FaxNumber: | 5085805162 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 07/27/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | CSW00760 | RI | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 1912942202 | 01 | RI | UBH | OTHER | 1104847946 | 01 | RI | THE PROVIDENCE CENTER NPI | OTHER | DO45951 | 05 | RI | MEDICAID |