Provider Demographics
NPI:1578680252
Name:COMMONWEALTH OF MASSACHUSETTS
Entity type:Organization
Organization Name:COMMONWEALTH OF MASSACHUSETTS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SITE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GLENNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOONEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-626-9300
Mailing Address - Street 1:170 MORTON ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-3735
Mailing Address - Country:US
Mailing Address - Phone:617-626-9300
Mailing Address - Fax:617-626-9591
Practice Address - Street 1:170 MORTON ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-3735
Practice Address - Country:US
Practice Address - Phone:617-626-9300
Practice Address - Fax:617-626-9591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1802313Medicaid