Provider Demographics
NPI:1225067481
Name:NORTHEAST HEALTH SERVICES, LLC
Entity Type:Organization
Organization Name:NORTHEAST HEALTH SERVICES, LLC
Other - Org Name:(DBA): ATTLEBORO BEHAVIORAL HEALTH CENTER/CAPE BEHAVIORAL HEALTH CENTE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WALLACE
Authorized Official - Middle Name:W
Authorized Official - Last Name:VARONKO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:508-830-1444
Mailing Address - Street 1:39A INDUSTRIAL PARK ROAD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-4868
Mailing Address - Country:US
Mailing Address - Phone:508-830-1444
Mailing Address - Fax:508-830-3655
Practice Address - Street 1:30 TAUNTON GREEN
Practice Address - Street 2:SUITE 5
Practice Address - City:TAUNTON
Practice Address - State:MA
Practice Address - Zip Code:02780-3243
Practice Address - Country:US
Practice Address - Phone:508-880-6666
Practice Address - Fax:508-880-6655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4570 AND 4984261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1311778Medicaid
MAM20623Medicare ID - Type Unspecified