Basic Information
| Provider Information | |||||||||
| NPI: | 1801916176 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILY SERVICE ASSOCIATION OF GREATER BOSTON | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FAMILY SERVICE OF GREATER BOSTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 31 HEATH ST | ||||||||
| Address2: | |||||||||
| City: | JAMAICA PLAIN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021301650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175236400 | ||||||||
| FaxNumber: | 6175233034 | ||||||||
| Practice Location | |||||||||
| Address1: | 31 HEATH ST | ||||||||
| Address2: | |||||||||
| City: | JAMAICA PLAIN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021301650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175236400 | ||||||||
| FaxNumber: | 6175233034 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2007 | ||||||||
| LastUpdateDate: | 12/29/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RUCKER | ||||||||
| AuthorizedOfficialFirstName: | RANDAL | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6175236400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MCP | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 4599 | MA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 1303414 | 05 | MA | MEDICAID | 1309404 | 05 | MA | MEDICAID | 1309374 | 05 | MA | MEDICAID |