Basic Information
| Provider Information | |||||||||
| NPI: | 1154457422 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PLYMOUTH COUNTY FOR BEHAVIORAL HEALTH LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PLYMOUTH CENTER FOR BEHAVIORAL HEALTH, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 34 MAIN STREET EXT | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023608302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088300012 | ||||||||
| FaxNumber: | 5088300092 | ||||||||
| Practice Location | |||||||||
| Address1: | 34 MAIN STREET EXT | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023608302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087894748 | ||||||||
| FaxNumber: | 5088300092 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2007 | ||||||||
| LastUpdateDate: | 06/23/2015 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | JULIE | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATER | ||||||||
| AuthorizedOfficialTelephone: | 5088300012 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PSY D | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.