Basic Information
| Provider Information | |||||||||
| NPI: | 1588093108 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH BAY MENTAL HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 W CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023017501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085804691 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1115 W CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023017501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085804691 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2013 | ||||||||
| LastUpdateDate: | 11/04/2013 | ||||||||
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| AuthorizedOfficialLastName: | GRACE | ||||||||
| AuthorizedOfficialFirstName: | SHAWNTAE | ||||||||
| AuthorizedOfficialMiddleName: | NICOLE | ||||||||
| AuthorizedOfficialTitleorPosition: | INTAKE LIASON | ||||||||
| AuthorizedOfficialTelephone: | 5088631584 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302F00000X | Y | Managed Care Organizations | Exclusive Provider Organization |
No ID Information.