Provider Demographics
NPI:1821117359
Name:COMMONWEALTH OF MASSACHUSETTS-DMH
Entity Type:Organization
Organization Name:COMMONWEALTH OF MASSACHUSETTS-DMH
Other - Org Name:BROCKTON MULTI SERVICE CENTER CASE MGMT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SITE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:JOBIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-897-2000
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:617-626-8000
Mailing Address - Fax:
Practice Address - Street 1:165 QUINCY ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-2988
Practice Address - Country:US
Practice Address - Phone:508-897-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAEXEMPT251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1802143Medicaid