Provider Demographics
NPI:1679608384
Name:PINE STREET INN
Entity type:Organization
Organization Name:PINE STREET INN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:LYNDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DOWNIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-892-9108
Mailing Address - Street 1:444 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2404
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:444 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2404
Practice Address - Country:US
Practice Address - Phone:617-892-9451
Practice Address - Fax:617-521-7621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0817251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1300130Medicaid