Provider Demographics
NPI:1811021090
Name:MASSACHUSETTS MENTOR LLC
Entity Type:Organization
Organization Name:MASSACHUSETTS MENTOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAIVD
Authorized Official - Middle Name:C
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-326-4207
Mailing Address - Street 1:280 BRIDGE ST
Mailing Address - Street 2:SUITE 230
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-1759
Mailing Address - Country:US
Mailing Address - Phone:781-326-4207
Mailing Address - Fax:781-326-4654
Practice Address - Street 1:280 BRIDGE ST
Practice Address - Street 2:SUITE 230
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-1759
Practice Address - Country:US
Practice Address - Phone:781-326-4207
Practice Address - Fax:781-326-4654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1615251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1904469Medicaid