Provider Demographics
NPI:1578843421
Name:SOUTH MIDDLESEX OPPORTUNITY COUNCIL
Entity Type:Organization
Organization Name:SOUTH MIDDLESEX OPPORTUNITY COUNCIL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF SUBSTANCE ABUSE
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:KINCHLA
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:508-879-2250
Mailing Address - Street 1:300 HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01702-8313
Mailing Address - Country:US
Mailing Address - Phone:508-879-2250
Mailing Address - Fax:508-879-2581
Practice Address - Street 1:300 HOWARD ST
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01702-8313
Practice Address - Country:US
Practice Address - Phone:508-879-2250
Practice Address - Fax:508-879-2581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-24
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110027995CMedicaid