Provider Demographics
NPI:1871715151
Name:MASSACHUSETTS GENERAL HOSPITAL REVERE HEALTHCARE CENTER
Entity type:Organization
Organization Name:MASSACHUSETTS GENERAL HOSPITAL REVERE HEALTHCARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARYKATE
Authorized Official - Middle Name:P
Authorized Official - Last Name:SHORTER
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:781-485-6112
Mailing Address - Street 1:416 MARLBOROUGH ST
Mailing Address - Street 2:#708
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-1544
Mailing Address - Country:US
Mailing Address - Phone:617-510-9458
Mailing Address - Fax:781-485-6119
Practice Address - Street 1:300 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-3675
Practice Address - Country:US
Practice Address - Phone:617-510-9458
Practice Address - Fax:781-485-6119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA111447261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)