Basic Information
| Provider Information | |||||||||
| NPI: | 1487944369 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTH BAY MENTAL HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SOUTH BAY EARLY INTERVENTION | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 133 CENTRE AVE | ||||||||
| Address2: | |||||||||
| City: | ABINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023512254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083803696 | ||||||||
| FaxNumber: | 5084275361 | ||||||||
| Practice Location | |||||||||
| Address1: | 1115 W CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023017501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085590473 | ||||||||
| FaxNumber: | 5084275361 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2011 | ||||||||
| LastUpdateDate: | 04/13/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FONSECA | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | NUNES | ||||||||
| AuthorizedOfficialTitleorPosition: | NURSE | ||||||||
| AuthorizedOfficialTelephone: | 5085590473 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 252Y00000X | 251934 | MA | Y | Agencies | Early Intervention Provider Agency |
No ID Information.