Healthcare Provider Details

I. General information

NPI: 1659387074
Provider Name (Legal Business Name): MARTHA'S VINEYARD COMMUNITY SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 10/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 EDGARTOWN RD
OAK BLUFFS MA
02557
US

IV. Provider business mailing address

111 EDGARTOWN RD
VINEYARD HAVEN MA
02568-5699
US

V. Phone/Fax

Practice location:
  • Phone: 508-693-7900
  • Fax:
Mailing address:
  • Phone: 508-693-7900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number2331
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2331
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: GLENN J STALGREN
Title or Position: BUSINESS ADMINISTRATOR
Credential: M.B.A.
Phone: 508-693-7900