Provider Demographics
NPI:1780862193
Name:MA DEPARTMENT OF DEVELOPMENTAL SERVICES
Entity Type:Organization
Organization Name:MA DEPARTMENT OF DEVELOPMENTAL SERVICES
Other - Org Name:DDS AUTISM WAIVER SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:JEANETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAILLET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-624-7814
Mailing Address - Street 1:500 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2439
Mailing Address - Country:US
Mailing Address - Phone:617-624-7878
Mailing Address - Fax:617-624-7575
Practice Address - Street 1:500 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2439
Practice Address - Country:US
Practice Address - Phone:617-624-7878
Practice Address - Fax:617-624-7575
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MA DEPARTMENT OF DEVELOPMENTAL SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-07
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1803875Medicaid