Provider Demographics
NPI:1124731476
Name:REUNITED
Entity type:Organization
Organization Name:REUNITED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTAKE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:GHOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:857-939-4445
Mailing Address - Street 1:1354 HANCOCK ST STE 205
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-5109
Mailing Address - Country:US
Mailing Address - Phone:857-939-4445
Mailing Address - Fax:
Practice Address - Street 1:1354 HANCOCK ST STE 205
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-5109
Practice Address - Country:US
Practice Address - Phone:857-939-4445
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-03
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1366796070Medicaid