Basic Information
| Provider Information | |||||||||
| NPI: | 1770528317 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTH SHORE MENTAL HEALTH CENTER INC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ASPIRE HEALTH ALLIANCE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 VICTORY RD | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021713139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6178471950 | ||||||||
| FaxNumber: | 6177869894 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | BRAINTREE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021847599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6178471950 | ||||||||
| FaxNumber: | 6177741490 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2006 | ||||||||
| LastUpdateDate: | 10/13/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ALLISON | ||||||||
| AuthorizedOfficialFirstName: | MAURA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 6178471902 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 459 | MA | N | Agencies | Community/Behavioral Health | 261QM0801X | 459 | MA | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 000000008462 | 01 | MA | BMC HEALTHNET PLAN | OTHER | 1303937 | 05 | MA | MEDICAID | 1800787 | 05 | MA | MEDICAID | 700251 | 01 | MA | TUFTS | OTHER | CH9016 | 01 | MA | RAILROAD MEDICARE | OTHER | 1002940 | 01 | MA | FALLON | OTHER | 156371000 | 01 | MA | CMSP | OTHER | 260000415 | 01 | MA | RAILROAD MEDICARE | OTHER | CD2672 | 01 | MA | RAILROAD MEDICARE | OTHER | M18467 | 01 | MA | BLUE CROSS | OTHER | 1300989 | 05 | MA | MEDICAID | M17211 | 01 | MA | BLUES | OTHER | 1303155 | 05 | MA | MEDICAID | 305535 | 01 | MA | TRICARE | OTHER | 1002940 | 01 | MA | BEACON HEALTH STRATEGIES | OTHER | 42723 | 01 | MA | MAGELLAN | OTHER | 68639 | 01 | MA | UBH | OTHER | SOU 2223001040 | 01 | MA | BLUE CROSS | OTHER |