Provider Demographics
NPI:1659644961
Name:BAY COVE HUMAN SERVICES, INC.
Entity Type:Organization
Organization Name:BAY COVE HUMAN SERVICES, INC.
Other - Org Name:ANDREW HOUSE DETOX
Other - Org Type:Other Name
Authorized Official - Title/Position:SVP FINANCE, CFO
Authorized Official - Prefix:
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:J
Authorized Official - Last Name:OLLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-371-3000
Mailing Address - Street 1:66 CANAL ST.
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-9660
Mailing Address - Country:US
Mailing Address - Phone:617-371-3000
Mailing Address - Fax:617-227-2454
Practice Address - Street 1:170 MORTON ST.
Practice Address - Street 2:4TH FLOOR SOUTH
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-6562
Practice Address - Country:US
Practice Address - Phone:617-318-5602
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BAY COVE HUMAN SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-02-16
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110026203CMedicaid