Basic Information
| Provider Information | |||||||||
| NPI: | 1255481107 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTH SUFFOLK MENTAL HEALTH ASSOCIATION, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | CHELSEA | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021502807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6178894860 | ||||||||
| FaxNumber: | 6178894635 | ||||||||
| Practice Location | |||||||||
| Address1: | 530 BORDER ST | ||||||||
| Address2: | |||||||||
| City: | EAST BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021282432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175696560 | ||||||||
| FaxNumber: | 6175691856 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MOORE | ||||||||
| AuthorizedOfficialFirstName: | JACKIE | ||||||||
| AuthorizedOfficialMiddleName: | K. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6179127910 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD1600X | CERTIFIED BY DPH | MA | Y | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 821870 | 01 | CT | AETNA-US HEALTHCARE | OTHER | 3836587 | 01 | CT | CIGNA | OTHER | 1800515 | 05 | MA | MEDICAID | 708502 | 01 | MA | TUFTS HEALTH PLAN | OTHER | 0006844 | 01 | MA | NEIGHBORHOOD HEALTH PLAN | OTHER | 42317215002 | 01 | TRICARE-CHAMPUS | OTHER | 612900 | 01 | MA | HARVARD PILGRIM | OTHER | EI0002 | 01 | MA | BLUE CROSS OF MA | OTHER | 00000005443 | 01 | MA | BMC HEALTHNET-EI | OTHER | 99625101 | 01 | MA | NETWORK HEALTH | OTHER |