Basic Information
| Provider Information | |||||||||
| NPI: | 1497830905 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH BAY MENTAL HEALTH CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 37 BELMONT ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023015299 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085804691 | ||||||||
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| Practice Location | |||||||||
| Address1: | 37 BELMONT ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023015299 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085804691 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SCANLON | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5085590473 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 4222 | MA | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | CP0064 | 01 | MA | NURSE SPECIALIST | OTHER |