Provider Demographics
NPI:1083732168
Name:DEPARTMENT OF MENTAL HEALTH
Entity Type:Organization
Organization Name:DEPARTMENT OF MENTAL HEALTH
Other - Org Name:B U FULLER IRTP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASST DIRECTOR OF NON-INST REIMBURSE
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:SCOPA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-886-8089
Mailing Address - Street 1:25 STANIFORD ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2503
Mailing Address - Country:US
Mailing Address - Phone:617-626-8040
Mailing Address - Fax:617-626-8295
Practice Address - Street 1:BOSTON UNIVERSITY - FULLER IRTP
Practice Address - Street 2:85 E NEWTON ST FL 6
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2340
Practice Address - Country:US
Practice Address - Phone:617-414-2005
Practice Address - Fax:617-414-2101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1103148Medicaid