Provider Demographics
NPI:1871765644
Name:SOMERVILLE MENTAL HEALTH ASSOCIATION, INC.
Entity type:Organization
Organization Name:SOMERVILLE MENTAL HEALTH ASSOCIATION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF MANAGAEMENT SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:MARITZA
Authorized Official - Middle Name:E
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-629-5341
Mailing Address - Street 1:167 HOLLAND ST
Mailing Address - Street 2:ROOM 133
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02144
Mailing Address - Country:US
Mailing Address - Phone:617-625-0710
Mailing Address - Fax:617-625-6339
Practice Address - Street 1:78 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02144-1916
Practice Address - Country:US
Practice Address - Phone:617-629-6624
Practice Address - Fax:617-625-6339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1305727Medicaid