Basic Information
| Provider Information | |||||||||
| NPI: | 1386963163 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIMOCK COMMUNITY HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 62 WYMAN STREET | ||||||||
| Address2: | |||||||||
| City: | JAMAICA PLAIN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174350999 | ||||||||
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| Practice Location | |||||||||
| Address1: | 55 DIMOCK ST | ||||||||
| Address2: | |||||||||
| City: | ROXBURY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021191029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174428800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2010 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | REID | ||||||||
| AuthorizedOfficialFirstName: | DEBORAH | ||||||||
| AuthorizedOfficialMiddleName: | SARAH | ||||||||
| AuthorizedOfficialTitleorPosition: | PSCHIATRIC TRIAGE COORDINTOR | ||||||||
| AuthorizedOfficialTelephone: | 6174428800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | L.C.S.W. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | 043487833 | MA | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QM0850X | 1326193269 | MA | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QM0850X | MA | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 043487833 | 05 | MA | MEDICAID |