Healthcare Provider Details

I. General information

NPI: 1407884059
Provider Name (Legal Business Name): THE COMMONWEALTH OF MASSACHUSETTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 08/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 QUINCY AVE
QUINCY MA
02169-8130
US

IV. Provider business mailing address

167 LYMAN ST
WESTBOROUGH MA
01581-2619
US

V. Phone/Fax

Practice location:
  • Phone: 617-626-9002
  • Fax: 617-770-2953
Mailing address:
  • Phone: 508-616-3500
  • Fax: 508-616-2859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number
License Number State

VIII. Authorized Official

Name: SUSAN WING
Title or Position: NE/SUBURBAN AREA DIRECTOR
Credential:
Phone: 508-616-3500