Basic Information
| Provider Information | |||||||||
| NPI: | 1659387074 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARTHA'S VINEYARD COMMUNITY SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 EDGARTOWN RD | ||||||||
| Address2: | |||||||||
| City: | VINEYARD HAVEN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 025685699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086937900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 111 EDGARTOWN RD | ||||||||
| Address2: | |||||||||
| City: | OAK BLUFFS | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5086937900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 10/28/2019 | ||||||||
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| AuthorizedOfficialLastName: | STALGREN | ||||||||
| AuthorizedOfficialFirstName: | GLENN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5086937900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.B.A. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 2331 | MA | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 2331 | MA | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 1310143 | 05 | MA | MEDICAID | M18486 | 01 | MA | BCBSMA PROVIDER # | OTHER | 1301543 | 05 | MA | MEDICAID |