Provider Demographics
NPI:1124273776
Name:NORTH SOFFOLK MENTAL HEALTH ASSOCIATION
Entity type:Organization
Organization Name:NORTH SOFFOLK MENTAL HEALTH ASSOCIATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CSP PROGRAM MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:OBEIRNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-912-7996
Mailing Address - Street 1:105 BELLINGHAM ST # 1
Mailing Address - Street 2:
Mailing Address - City:CHELSEA
Mailing Address - State:MA
Mailing Address - Zip Code:02150-3201
Mailing Address - Country:US
Mailing Address - Phone:617-912-7969
Mailing Address - Fax:617-887-1889
Practice Address - Street 1:105 BELLINGHAM ST # 1
Practice Address - Street 2:
Practice Address - City:CHELSEA
Practice Address - State:MA
Practice Address - Zip Code:02150-3201
Practice Address - Country:US
Practice Address - Phone:617-912-7969
Practice Address - Fax:617-887-1889
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NO BUSINESS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-24
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1192251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1192Medicaid