MEDICARE: MASSACHUSETTS MENTOR LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	1615	MA
2	253J00000X	Foster Care Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811021090
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MASSACHUSETTS MENTOR LLC

Provider Business Mailing Address
First Line	:	1115 W CHESTNUT ST STE 202
Second Line	:
City	:	BROCKTON
State	:	MA
Zip	:	02301-7501
Country	:	US
Telephone Number	:	508-824-1355
Fax Number	:	508-824-3732

Provider Business Practice Location Address
First Line	:	1115 W CHESTNUT ST STE 202
Second Line	:
City	:	BROCKTON
State	:	MA
Zip	:	02301-7501
Country	:	US
Telephone Number	:	781-326-4207
Fax Number	:	781-326-4654

Authorized Official
Title or Position	:	STATE DIRECTOR
Name	:	RYAN JAMES LOVELADY
Credential	:
Telephone Number	:	862-284-4565

Provider Enumeration Date	:	03/16/2007
Last Update Date	:	08/21/2025

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