Provider Demographics
NPI:1194840975
Name:COMMONWEALTH OF MASSACHUSETTS
Entity Type:Organization
Organization Name:COMMONWEALTH OF MASSACHUSETTS
Other - Org Name:DEPARTMENT OF MENTAL HEALTH - MASS MENTAL HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CENTER DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-626-9459
Mailing Address - Street 1:75 FENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-6103
Mailing Address - Country:US
Mailing Address - Phone:617-626-9459
Mailing Address - Fax:
Practice Address - Street 1:75 FENWOOD RD
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6103
Practice Address - Country:US
Practice Address - Phone:617-626-9459
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1310046Medicaid