Basic Information
| Provider Information | |||||||||
| NPI: | 1578843421 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH MIDDLESEX OPPORTUNITY COUNCIL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 HOWARD ST | ||||||||
| Address2: | |||||||||
| City: | FRAMINGHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017028313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088792250 | ||||||||
| FaxNumber: | 5088792581 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 HOWARD ST | ||||||||
| Address2: | |||||||||
| City: | FRAMINGHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017028313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088792250 | ||||||||
| FaxNumber: | 5088792581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2011 | ||||||||
| LastUpdateDate: | 08/24/2011 | ||||||||
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| AuthorizedOfficialLastName: | KINCHLA | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF SUBSTANCE ABUSE | ||||||||
| AuthorizedOfficialTelephone: | 5088792250 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PSYD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 110027995C | 05 | MA | MEDICAID |