Basic Information
| Provider Information | |||||||||
| NPI: | 1740723436 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GANDARA MENTAL HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011032203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4138460445 | ||||||||
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| Practice Location | |||||||||
| Address1: | 120 MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011032203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4138460445 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2016 | ||||||||
| LastUpdateDate: | 11/29/2016 | ||||||||
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| AuthorizedOfficialLastName: | LASANTA | ||||||||
| AuthorizedOfficialFirstName: | LEONEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CLINICIAN | ||||||||
| AuthorizedOfficialTelephone: | 4138460445 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 1134107113 | 01 | MA | NHP | OTHER | 1134107113 | 01 | MA | MBHP | OTHER | 1134107113 | 01 | MA | BEACON | OTHER | 71756 | 01 | MA | TUFTS | OTHER | 12529 | 01 | MA | HNE | OTHER | 997303 | 01 | MA | NETWORK HEALTH | OTHER | 1134107113 | 01 | MA | FALLON | OTHER | 1307576 | 05 | MA | MEDICAID |