Provider Demographics
NPI:1295855856
Name:COMMONWEALTH OF MASSACHUSETTS-DMH
Entity Type:Organization
Organization Name:COMMONWEALTH OF MASSACHUSETTS-DMH
Other - Org Name:SOUTH SUBURBAN SITE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SITE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-626-9023
Mailing Address - Street 1:460 QUINCY AVE
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-8130
Mailing Address - Country:US
Mailing Address - Phone:617-626-9018
Mailing Address - Fax:
Practice Address - Street 1:460 QUINCY AVE
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-8130
Practice Address - Country:US
Practice Address - Phone:617-626-9018
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1802402Medicaid