1699956714 NPI number — WHITTIER STREET HEALTH CENTER BEHAVIORAL HEALTH

Table of content: (NPI 1699956714)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699956714 NPI number — WHITTIER STREET HEALTH CENTER BEHAVIORAL HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WHITTIER STREET HEALTH CENTER BEHAVIORAL HEALTH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699956714
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1290 TREMONT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROXBURY CROSSING
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02120-3432
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-427-1000
Provider Business Mailing Address Fax Number:
617-858-2674

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1290 TREMONT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROXBURY CROSSING
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02120-3432
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-427-1000
Provider Business Practice Location Address Fax Number:
617-858-2674
Provider Enumeration Date:
11/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BRODIE
Authorized Official First Name:
JANE
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT BEHAVIORAL HEALTH
Authorized Official Telephone Number:
617-989-3077

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X , with the licence number:  4144 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: Y55112 . This is a "MEDICARE PART B CARRIER" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1399578 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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