Basic Information
| Provider Information | |||||||||
| NPI: | 1528456498 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH BAY MENTAL HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1651 LIBERTY ST | ||||||||
| Address2: | |||||||||
| City: | BRAINTREE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021848274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818486704 | ||||||||
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| Practice Location | |||||||||
| Address1: | 103 COMMERCIAL ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023023101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085804691 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/31/2014 | ||||||||
| LastUpdateDate: | 12/31/2014 | ||||||||
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| AuthorizedOfficialLastName: | MEISTER | ||||||||
| AuthorizedOfficialFirstName: | ALAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5084364432 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 220429 | MA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 220429 | 01 | MA | LCSW | OTHER |