Provider Demographics
NPI:1649658741
Name:PINE STREET INN
Entity type:Organization
Organization Name:PINE STREET INN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:IMELDA
Authorized Official - Last Name:FITZPATRICK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:617-892-7893
Mailing Address - Street 1:1220 ADAMS ST
Mailing Address - Street 2:G17
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02124-5752
Mailing Address - Country:US
Mailing Address - Phone:917-334-2916
Mailing Address - Fax:
Practice Address - Street 1:170 MORTON ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02130-3735
Practice Address - Country:US
Practice Address - Phone:617-892-7893
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-11
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA220519276400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit