Provider Demographics
NPI:1346641313
Name:PENIKESE ISLAND SCHOOL, INC
Entity Type:Organization
Organization Name:PENIKESE ISLAND SCHOOL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/THIRD PARTY BILLING
Authorized Official - Prefix:MRS
Authorized Official - First Name:MANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSAKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-353-9102
Mailing Address - Street 1:PO BOX 161
Mailing Address - Street 2:
Mailing Address - City:WOODS HOLE
Mailing Address - State:MA
Mailing Address - Zip Code:02543-0161
Mailing Address - Country:US
Mailing Address - Phone:508-548-7276
Mailing Address - Fax:508-457-9580
Practice Address - Street 1:565 WOODS HOLE RD
Practice Address - Street 2:
Practice Address - City:WOODS HOLE
Practice Address - State:MA
Practice Address - Zip Code:02543-1041
Practice Address - Country:US
Practice Address - Phone:508-548-7276
Practice Address - Fax:508-457-9580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-10
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0203320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness