Healthcare Provider Details

I. General information

NPI: 1184981284
Provider Name (Legal Business Name): PINESTREET INN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2012
Last Update Date: 05/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 MORTON ST
JAMAICA PLAIN MA
02130-3735
US

IV. Provider business mailing address

444 HARRISON AVE
BOSTON MA
02118-2404
US

V. Phone/Fax

Practice location:
  • Phone: 617-892-9451
  • Fax: 617-521-7261
Mailing address:
  • Phone: 617-892-9451
  • Fax: 617-521-7261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number0817
License Number StateMA

VIII. Authorized Official

Name: MRS. LYNDIA DOWNEY
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 617-892-9105