Provider Demographics
NPI:1366506677
Name:OLD COLONY YOUNG MEN'S CHRISTIAN ASSOCIATION, INC.
Entity Type:Organization
Organization Name:OLD COLONY YOUNG MEN'S CHRISTIAN ASSOCIATION, INC.
Other - Org Name:OLD COLONY Y COMPREHENSIVE COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EVP, CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:J
Authorized Official - Last Name:DESMOND
Authorized Official - Suffix:
Authorized Official - Credentials:CPA, MBA
Authorized Official - Phone:508-897-1230
Mailing Address - Street 1:104 TORREY STREET
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-4855
Mailing Address - Country:US
Mailing Address - Phone:508-427-4383
Mailing Address - Fax:508-584-4328
Practice Address - Street 1:104 TORREY STREET
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-4855
Practice Address - Country:US
Practice Address - Phone:508-427-4383
Practice Address - Fax:508-584-4328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4796103TC0700X, 1041C0700X, 2084P0804X
174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1319736Medicaid