Provider Demographics
NPI:1710004858
Name:COMMONWEALTH OF MASSCHUSETTS
Entity Type:Organization
Organization Name:COMMONWEALTH OF MASSCHUSETTS
Other - Org Name:DEPARTMENT OF MENTAL HEALTH - CAMBRIDGE SOMERVILLE OFFICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SITE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:LICCIARDELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-626-4800
Mailing Address - Street 1:2400 MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02140-1854
Mailing Address - Country:US
Mailing Address - Phone:617-626-4800
Mailing Address - Fax:617-497-6128
Practice Address - Street 1:2400 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02140-1854
Practice Address - Country:US
Practice Address - Phone:617-626-4800
Practice Address - Fax:617-497-6128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1802151Medicaid