MEDICARE: NATIONAL MENTOR HEALTHCARE NETWORK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst
2	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	4060096	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013093616
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NATIONAL MENTOR HEALTHCARE NETWORK

Provider Business Mailing Address
First Line	:	313 CONGRESS ST
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02210-1218
Country	:	US
Telephone Number	:	800-388-5150
Fax Number	:	617-790-4271

Provider Business Practice Location Address
First Line	:	4550 RICKER RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32210-6308
Country	:	US
Telephone Number	:	904-778-0935
Fax Number	:	904-778-8396

Authorized Official
Title or Position	:	COO
Name	:	BRETT IAN COHEN
Credential	:
Telephone Number	:	800-388-5150

Provider Enumeration Date	:	10/27/2006
Last Update Date	:	03/04/2023

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Directions to “NATIONAL MENTOR HEALTHCARE NETWORK ” Practice Location

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