Healthcare Provider Details

I. General information

NPI: 1487510830
Provider Name (Legal Business Name): CITYWIDE BEHAVIORAL HEALTH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2025
Last Update Date: 12/30/2025
Certification Date: 12/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 WEBSTER ST STE 1
HANOVER MA
02339-1200
US

IV. Provider business mailing address

25 SIMPSON ST
NEWTON MA
02458-2225
US

V. Phone/Fax

Practice location:
  • Phone: 781-429-7755
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SLAVA ISMINTSEV
Title or Position: OWNER
Credential:
Phone: 617-699-5845