Basic Information
| Provider Information | |||||||||
| NPI: | 1881782522 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NOVA PSYCHIATRIC SERVICES, PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PRIME BEHAVIORAL HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1261 FURNACE BROOK PARKWAY SUITE 31 | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021694721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174794545 | ||||||||
| FaxNumber: | 6174794555 | ||||||||
| Practice Location | |||||||||
| Address1: | 234 COPELAND STREET STE 320 | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021694762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174794545 | ||||||||
| FaxNumber: | 6174794555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 03/28/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ACCARDI | ||||||||
| AuthorizedOfficialFirstName: | ALEXANDRA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR, OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6174794545 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 03/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 110072540A | 05 | MA | MEDICAID |