Basic Information
| Provider Information | |||||||||
| NPI: | 1699956714 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WHITTIER STREET HEALTH CENTER BEHAVIORAL HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | WHITTIER STREET HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1290 TREMONT ST | ||||||||
| Address2: | |||||||||
| City: | ROXBURY CROSSING | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021203432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174271000 | ||||||||
| FaxNumber: | 6178582674 | ||||||||
| Practice Location | |||||||||
| Address1: | 1290 TREMONT ST | ||||||||
| Address2: | |||||||||
| City: | ROXBURY CROSSING | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021203432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174271000 | ||||||||
| FaxNumber: | 6178582674 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2007 | ||||||||
| LastUpdateDate: | 06/30/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRODIE | ||||||||
| AuthorizedOfficialFirstName: | JANE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT BEHAVIORAL HEALTH | ||||||||
| AuthorizedOfficialTelephone: | 6179893077 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WHITTIER STREET HEALTH CENTER COMMITTEE INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 4144 | MA | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | Y55112 | 01 | MA | MEDICARE PART B CARRIER | OTHER | 1399578 | 05 | MA | MEDICAID |