Basic Information
| Provider Information | |||||||||
| NPI: | 1508243247 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARTHA'SVINYARD COMMUNITY SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 EDGARTOWN RD | ||||||||
| Address2: | |||||||||
| City: | VINEYARD HAVEN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 025685699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086937900 | ||||||||
| FaxNumber: | 5086960401 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 EDGARTOWN RD | ||||||||
| Address2: | |||||||||
| City: | VINEYARD HAVEN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 025685699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086937900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2015 | ||||||||
| LastUpdateDate: | 05/01/2015 | ||||||||
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| AuthorizedOfficialLastName: | KRETSCHMANN | ||||||||
| AuthorizedOfficialFirstName: | KATHLEEN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | INTEGRATED CARE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5086937900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 127434 | MA | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.