Basic Information
| Provider Information | |||||||||
| NPI: | 1124273776 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTH SOFFOLK MENTAL HEALTH ASSOCIATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CHELSEA COLLABORATIVE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 105 BELLINGHAM ST # 1 | ||||||||
| Address2: | |||||||||
| City: | CHELSEA | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021503201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6179127969 | ||||||||
| FaxNumber: | 6178871889 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 BELLINGHAM ST # 1 | ||||||||
| Address2: | |||||||||
| City: | CHELSEA | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021503201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6179127969 | ||||||||
| FaxNumber: | 6178871889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2008 | ||||||||
| LastUpdateDate: | 11/24/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | OBEIRNE | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CSP PROGRAM MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6179127996 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NO BUSINESS | ||||||||
| AuthorizedOfficialNamePrefix: | MISS | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | 1192 | MA | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 1192 | 05 | MA | MEDICAID |