Provider Demographics
NPI:1659387074
Name:MARTHA'S VINEYARD COMMUNITY SERVICES, INC.
Entity Type:Organization
Organization Name:MARTHA'S VINEYARD COMMUNITY SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:J
Authorized Official - Last Name:STALGREN
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:508-693-7900
Mailing Address - Street 1:111 EDGARTOWN RD
Mailing Address - Street 2:
Mailing Address - City:VINEYARD HAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02568-5699
Mailing Address - Country:US
Mailing Address - Phone:508-693-7900
Mailing Address - Fax:
Practice Address - Street 1:111 EDGARTOWN RD
Practice Address - Street 2:
Practice Address - City:OAK BLUFFS
Practice Address - State:MA
Practice Address - Zip Code:02557
Practice Address - Country:US
Practice Address - Phone:508-693-7900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2331101YA0400X, 101YM0800X
261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1310143Medicaid
MAM18486OtherBCBSMA PROVIDER #
MA1301543Medicaid
MA1301543Medicaid