Basic Information
| Provider Information | |||||||||
| NPI: | 1265771141 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLLABORATIVE MENTAL HEALTH SERVICES INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 246 WALNUT ST | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | NEWTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024601689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172443322 | ||||||||
| FaxNumber: | 6175816040 | ||||||||
| Practice Location | |||||||||
| Address1: | 264 UNION AVE | ||||||||
| Address2: | |||||||||
| City: | FRAMINGHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017026348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7815912775 | ||||||||
| FaxNumber: | 7742444129 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2013 | ||||||||
| LastUpdateDate: | 02/12/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FERRELL | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7815912775 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0809X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Adult | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.