Provider Demographics
NPI:1003038365
Name:MA DEPARTMENT OF YOUTH SERVICES
Entity Type:Organization
Organization Name:MA DEPARTMENT OF YOUTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUDGET DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:EGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-960-3258
Mailing Address - Street 1:27 WORMWOOD STREET
Mailing Address - Street 2:SUITE 400
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02210
Mailing Address - Country:US
Mailing Address - Phone:617-727-7575
Mailing Address - Fax:617-951-2409
Practice Address - Street 1:27 WORMWOOD STREET
Practice Address - Street 2:SUITE 400
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02210
Practice Address - Country:US
Practice Address - Phone:617-727-7575
Practice Address - Fax:617-951-2409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1803867Medicaid