Healthcare Provider Details

I. General information

NPI: 1144768045
Provider Name (Legal Business Name): COMMONWEALTH OF MASSACHUSETTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2017
Last Update Date: 02/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 QUINCY ST
BROCKTON MA
02302-2988
US

IV. Provider business mailing address

165 QUINCY ST.
BROCKTON MA
02301
US

V. Phone/Fax

Practice location:
  • Phone: 508-897-2100
  • Fax: 508-586-5117
Mailing address:
  • Phone: 508-897-2100
  • Fax: 508-586-5117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberLN25249
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MERLEEN MILLS
Title or Position: DIRTECTOR OF EMERGENCY SERVICES
Credential: LICSW
Phone: 508-285-9400