Provider Demographics
NPI:1174677223
Name:DIMOCK COMMUNITY SERVICES CORP
Entity Type:Organization
Organization Name:DIMOCK COMMUNITY SERVICES CORP
Other - Org Name:DIMOCK EARLY INTERVENTION
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR IT & AR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-442-8800
Mailing Address - Street 1:55 DIMOCK ST
Mailing Address - Street 2:
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02119-1029
Mailing Address - Country:US
Mailing Address - Phone:617-442-8800
Mailing Address - Fax:617-445-0091
Practice Address - Street 1:1800 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-1042
Practice Address - Country:US
Practice Address - Phone:617-442-8800
Practice Address - Fax:617-445-0091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1887297Medicaid