Provider Demographics
NPI:1053135087
Name:IWANICKI, IAN GEREK
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:GEREK
Last Name:IWANICKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:867 BOYLSTON STREET
Mailing Address - Street 2:5TH FLOOR #2050
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116
Mailing Address - Country:US
Mailing Address - Phone:617-356-7787
Mailing Address - Fax:857-264-5776
Practice Address - Street 1:867 BOYLSTON STREET
Practice Address - Street 2:5TH FLOOR #2050
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116
Practice Address - Country:US
Practice Address - Phone:617-356-7787
Practice Address - Fax:857-264-5776
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-15
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health