Healthcare Provider Details

I. General information

NPI: 1366506677
Provider Name (Legal Business Name): OLD COLONY YOUNG MEN'S CHRISTIAN ASSOCIATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 03/01/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 TORREY STREET
BROCKTON MA
02301-4855
US

IV. Provider business mailing address

104 TORREY STREET
BROCKTON MA
02301-4855
US

V. Phone/Fax

Practice location:
  • Phone: 508-427-4383
  • Fax: 508-584-4328
Mailing address:
  • Phone: 508-427-4383
  • Fax: 508-584-4328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4796
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number4796
License Number StateMA
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number4796
License Number StateMA

VIII. Authorized Official

Name: MS. DONNA J DESMOND
Title or Position: EVP, CFO
Credential: CPA, MBA
Phone: 508-897-1230