Provider Demographics
NPI:1386839629
Name:MASS GENERAL REVERE HEALTHCARE CENTER
Entity Type:Organization
Organization Name:MASS GENERAL REVERE HEALTHCARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MISS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:781-495-6039
Mailing Address - Street 1:300 OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-3675
Mailing Address - Country:US
Mailing Address - Phone:781-485-6000
Mailing Address - Fax:781-485-6230
Practice Address - Street 1:300 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-3675
Practice Address - Country:US
Practice Address - Phone:781-485-6000
Practice Address - Fax:781-485-6230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA214161251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health