Basic Information
| Provider Information | |||||||||
| NPI: | 1740209881 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH SUFFOLK MENTAL HEALTH ASSOCIATION, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | CHELSEA | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021502807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6178894860 | ||||||||
| FaxNumber: | 6178894635 | ||||||||
| Practice Location | |||||||||
| Address1: | 14 PORTER ST | ||||||||
| Address2: | |||||||||
| City: | EAST BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021282116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175693189 | ||||||||
| FaxNumber: | 6175697890 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 07/10/2008 | ||||||||
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| AuthorizedOfficialLastName: | MOORE | ||||||||
| AuthorizedOfficialFirstName: | JACKIE | ||||||||
| AuthorizedOfficialMiddleName: | K. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6179127910 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 4027 | MA | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 1307398 | 05 | MA | MEDICAID | M18732 | 01 | MA | BLUE CROSS OF MA | OTHER | 1304178 | 05 | MA | MEDICAID | 1303147 | 05 | MA | MEDICAID | 7216 | 01 | MA | BMC HEALTHNET | OTHER | 996251-01 | 01 | MA | NETWORK HEALTH | OTHER | 1301659 | 05 | MA | MEDICAID | 1301926 | 05 | MA | MEDICAID | 214325 | 01 | MA | MAGELLAN BEHAVIORAL HLTH | OTHER | A012487 | 01 | MA | MASS. BEHAVIORAL HEALTH PARTNERSHIP NODDLES ISLAND | OTHER | 1002420 | 01 | MA | BEACON HEALTH STRATEGIES | OTHER | 708502 | 01 | MA | TUFTS HEALTH PLANS | OTHER | A011775 | 01 | MA | MASS. BEHAVIORAL HEALTH PARTNERSHIP | OTHER |