Basic Information
| Provider Information | |||||||||
| NPI: | 1982900163 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GANDARA MENTAL HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 147 NORMAN ST | ||||||||
| Address2: | |||||||||
| City: | WEST SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010895003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137368329 | ||||||||
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| Practice Location | |||||||||
| Address1: | 147 NORMAN ST | ||||||||
| Address2: | |||||||||
| City: | WEST SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010895003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137368329 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2011 | ||||||||
| LastUpdateDate: | 02/04/2011 | ||||||||
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| AuthorizedOfficialLastName: | EAST-TROU | ||||||||
| AuthorizedOfficialFirstName: | HENRY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4137368329 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | M18463 | 01 | MA | BLUE CROSS/BLUE SHIELD | OTHER | 1307576 | 05 | MA | MEDICAID |