Healthcare Provider Details

I. General information

NPI: 1750654315
Provider Name (Legal Business Name): NORTHEAST BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2012
Last Update Date: 02/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 MERRIMACK ST
HAVERHILL MA
01830-6207
US

IV. Provider business mailing address

60 MERRIMACK ST
HAVERHILL MA
01830-6207
US

V. Phone/Fax

Practice location:
  • Phone: 978-373-1126
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier1154302586
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer

VIII. Authorized Official

Name: LESLIE BALOGNA
Title or Position: INTERN
Credential: MA
Phone: 978-373-1126