Healthcare Provider Details

I. General information

NPI: 1386555035
Provider Name (Legal Business Name): MASS MENTAL HEALTH FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6041 BRISTOL PKWY STE 100
CULVER CITY CA
90230-6601
US

IV. Provider business mailing address

2555 MADISON AVE
BALTIMORE MD
21217-4041
US

V. Phone/Fax

Practice location:
  • Phone: 443-808-0537
  • Fax:
Mailing address:
  • Phone: 443-808-0537
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MS. FATIMA DISU
Title or Position: PRESIDENT
Credential:
Phone: 410-299-0875