Provider Demographics
NPI:1134107113
Name:GANDARA MENTAL HEALTH CENTER INC
Entity Type:Organization
Organization Name:GANDARA MENTAL HEALTH CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:EAST-TROU
Authorized Official - Suffix:
Authorized Official - Credentials:PHD LMHC
Authorized Official - Phone:413-736-8329
Mailing Address - Street 1:147 NORMAN ST
Mailing Address - Street 2:
Mailing Address - City:WEST SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01089-5003
Mailing Address - Country:US
Mailing Address - Phone:413-736-8329
Mailing Address - Fax:413-746-4270
Practice Address - Street 1:2155 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104
Practice Address - Country:US
Practice Address - Phone:413-736-0395
Practice Address - Fax:413-734-1651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-09
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA217101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1307576Medicaid
MA1303295Medicaid
Y10086Medicare ID - Type Unspecified