Basic Information
| Provider Information | |||||||||
| NPI: | 1871715151 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MASSACHUSETTS GENERAL HOSPITAL REVERE HEALTHCARE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 416 MARLBOROUGH ST | ||||||||
| Address2: | #708 | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021151544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175109458 | ||||||||
| FaxNumber: | 7814856119 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 OCEAN AVE | ||||||||
| Address2: | |||||||||
| City: | REVERE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021513675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175109458 | ||||||||
| FaxNumber: | 7814856119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SHORTER | ||||||||
| AuthorizedOfficialFirstName: | MARYKATE | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | SOCIAL WORKER | ||||||||
| AuthorizedOfficialTelephone: | 7814856112 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | LICSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 111447 | MA | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.