Healthcare Provider Details

I. General information

NPI: 1639425317
Provider Name (Legal Business Name): MARTHAS VINEYARD COMMUNITY SERVICES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2012
Last Update Date: 07/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 EDGARTOWN ROAD
VINEYARD HAVEN MA
02568
US

IV. Provider business mailing address

111 EDGARTOWN RD
VINEYARD HAVEN MA
02568-5601
US

V. Phone/Fax

Practice location:
  • Phone: 508-693-7900
  • Fax: 508-693-7192
Mailing address:
  • Phone: 508-693-7900
  • Fax: 508-693-7192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number261QM0801X
License Number StateMA

VIII. Authorized Official

Name: JANE SARNO
Title or Position: CLINICIAN
Credential: MSW
Phone: 508-693-7900