Provider Demographics
NPI:1710004320
Name:DEPARTMENT OF MENTAL HEALTH
Entity Type:Organization
Organization Name:DEPARTMENT OF MENTAL HEALTH
Other - Org Name:MERRIMACK CENTER BIRTP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASST. DIRECTOR OF NON-INST REIMBURS
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:SCOPA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-886-8089
Mailing Address - Street 1:25 STANIFORD ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2503
Mailing Address - Country:US
Mailing Address - Phone:617-626-8040
Mailing Address - Fax:617-626-8295
Practice Address - Street 1:TEWKSBURY STATE HOSP SPECIAL BLDG - MERRIMACK CTR BIRTP
Practice Address - Street 2:365 EAST ST
Practice Address - City:TEWKSBURY
Practice Address - State:MA
Practice Address - Zip Code:01876
Practice Address - Country:US
Practice Address - Phone:978-858-3776
Practice Address - Fax:978-858-3494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1199234Medicaid