Provider Demographics
NPI:1699956714
Name:WHITTIER STREET HEALTH CENTER BEHAVIORAL HEALTH
Entity type:Organization
Organization Name:WHITTIER STREET HEALTH CENTER BEHAVIORAL HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT BEHAVIORAL HEALTH
Authorized Official - Prefix:MR
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRODIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-989-3077
Mailing Address - Street 1:1290 TREMONT ST
Mailing Address - Street 2:
Mailing Address - City:ROXBURY CROSSING
Mailing Address - State:MA
Mailing Address - Zip Code:02120-3432
Mailing Address - Country:US
Mailing Address - Phone:617-427-1000
Mailing Address - Fax:617-858-2674
Practice Address - Street 1:1290 TREMONT ST
Practice Address - Street 2:
Practice Address - City:ROXBURY CROSSING
Practice Address - State:MA
Practice Address - Zip Code:02120-3432
Practice Address - Country:US
Practice Address - Phone:617-427-1000
Practice Address - Fax:617-858-2674
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WHITTIER STREET HEALTH CENTER COMMITTEE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-16
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4144261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY55112OtherMEDICARE PART B CARRIER
MA1399578Medicaid
MA221824Medicare Oscar/Certification