Provider Demographics
NPI:1801916176
Name:FAMILY SERVICE ASSOCIATION OF GREATER BOSTON
Entity type:Organization
Organization Name:FAMILY SERVICE ASSOCIATION OF GREATER BOSTON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDAL
Authorized Official - Middle Name:D
Authorized Official - Last Name:RUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:MCP
Authorized Official - Phone:617-523-6400
Mailing Address - Street 1:31 HEATH ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-1650
Mailing Address - Country:US
Mailing Address - Phone:617-523-6400
Mailing Address - Fax:617-523-3034
Practice Address - Street 1:31 HEATH ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-1650
Practice Address - Country:US
Practice Address - Phone:617-523-6400
Practice Address - Fax:617-523-3034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4599251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1303414Medicaid
MA1309404Medicaid
MA1309374Medicaid
MAP10142Medicare ID - Type Unspecified
MA1309374Medicaid
MAP21976Medicare UPIN
MAP04427Medicare UPIN
MA1303414Medicaid
MA1309404Medicaid
MAP23746Medicare UPIN
MAY10252Medicare ID - Type Unspecified