Basic Information
| Provider Information | |||||||||
| NPI: | 1225067481 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHEAST HEALTH SERVICES, LLC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | (DBA): ATTLEBORO BEHAVIORAL HEALTH CENTER/CAPE BEHAVIORAL HEALTH CENTE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 39A INDUSTRIAL PARK ROAD | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023604868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088301444 | ||||||||
| FaxNumber: | 5088303655 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 TAUNTON GREEN | ||||||||
| Address2: | SUITE 5 | ||||||||
| City: | TAUNTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027803243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088806666 | ||||||||
| FaxNumber: | 5088806655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2006 | ||||||||
| LastUpdateDate: | 08/24/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | VARONKO | ||||||||
| AuthorizedOfficialFirstName: | WALLACE | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5088301444 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 4570 AND 4984 | MA | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 1311778 | 05 | MA | MEDICAID |