Provider Demographics
NPI:1326053786
Name:MELROSE-WAKEFIELD BEHAVORIAL HEALTH CENTER, P.C.
Entity Type:Organization
Organization Name:MELROSE-WAKEFIELD BEHAVORIAL HEALTH CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LALITH
Authorized Official - Middle Name:M
Authorized Official - Last Name:TISSERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-224-0661
Mailing Address - Street 1:800 W CUMMINGS PARK
Mailing Address - Street 2:SUITE 4700
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-6372
Mailing Address - Country:US
Mailing Address - Phone:781-224-0661
Mailing Address - Fax:781-224-1993
Practice Address - Street 1:800 W CUMMINGS PARK
Practice Address - Street 2:SUITE 4700
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-6372
Practice Address - Country:US
Practice Address - Phone:781-224-0661
Practice Address - Fax:781-224-1993
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MELROSE-WAKEFIELD BEHAVORIAL HEALTH CENTER, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-31
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA816352084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3143741Medicaid
MA007792OtherVALUE OPTIONS
MAM21864OtherMEDICARE PIN
MAG10083OtherMEDICARE UPIN
MD007792OtherVALUE OPTIONS
MA3143741OtherMEDICAID
MA776747OtherTUFTS
MAM19048OtherBLUE CROSS BLUE SHIELD
MA222936OtherPACIFICARE
MAA20487OtherMEDICARE
MAJ16485OtherBLUECROSSBLUE SHIELD
MAG10083OtherMEDICARE UPIN
MA3143741Medicaid
MA776747OtherTUFTS
MAM21864OtherMEDICARE PIN
MA776747OtherTUFTS