Provider Demographics
NPI:1811021090
Name:MASSACHUSETTS MENTOR LLC
Entity type:Organization
Organization Name:MASSACHUSETTS MENTOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STATE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:LOVELADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:862-284-4565
Mailing Address - Street 1:1115 W CHESTNUT ST STE 202
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-7501
Mailing Address - Country:US
Mailing Address - Phone:508-824-1355
Mailing Address - Fax:508-824-3732
Practice Address - Street 1:1115 W CHESTNUT ST STE 202
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-7501
Practice Address - Country:US
Practice Address - Phone:781-326-4207
Practice Address - Fax:781-326-4654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2025-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1615251S00000X
253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1904469Medicaid