Provider Demographics
NPI:1740723436
Name:GANDARA MENTAL HEALTH CENTER
Entity type:Organization
Organization Name:GANDARA MENTAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LEONEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LASANTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:413-846-0445
Mailing Address - Street 1:120 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01103-2203
Mailing Address - Country:US
Mailing Address - Phone:413-846-0445
Mailing Address - Fax:
Practice Address - Street 1:120 MAPLE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103-2203
Practice Address - Country:US
Practice Address - Phone:413-846-0445
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-29
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1134107113OtherNHP
MA1134107113OtherMBHP
MA1134107113OtherBEACON
MA71756OtherTUFTS
MA12529OtherHNE
MA997303OtherNETWORK HEALTH
MA1134107113OtherFALLON
MA1307576Medicaid
MA1307576Medicaid
MAY10086Medicare PIN