Basic Information
| Provider Information | |||||||||
| NPI: | 1639572779 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTH SHORE MENTAL HEALTH, INC. | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | STEP ONE EARLY INTERVENTION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 VICTORY ROAD | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021713139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6178471950 | ||||||||
| FaxNumber: | 6177869894 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 MOON ISLAND RD | ||||||||
| Address2: | |||||||||
| City: | SQUANTUM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021711034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6178471950 | ||||||||
| FaxNumber: | 6177869894 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2014 | ||||||||
| LastUpdateDate: | 10/03/2014 | ||||||||
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| AuthorizedOfficialLastName: | WOJCIK | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT/TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 6178471950 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD1600X | 459 | MA | Y | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | EI0013 | 01 | BLUE CROSS | OTHER |