Provider Demographics
NPI:1356569149
Name:DEPARTMENT OF MENTAL HEALTH
Entity type:Organization
Organization Name:DEPARTMENT OF MENTAL HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SITE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MINCHOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-363-2121
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:
Mailing Address - Fax:
Practice Address - Street 1:305 BELMONT ST
Practice Address - Street 2:WORCESTER CM
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01604-1681
Practice Address - Country:US
Practice Address - Phone:508-363-2121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1802445Medicaid