Healthcare Provider Details

I. General information

NPI: 1780025189
Provider Name (Legal Business Name): SOUTH BAY MENTAL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2013
Last Update Date: 07/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 S POINT DR APARTMENT 605
BOSTON MA
02125-3564
US

IV. Provider business mailing address

15 S POINT DR APARTMENT 605
BOSTON MA
02125-3564
US

V. Phone/Fax

Practice location:
  • Phone: 857-225-6908
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: KAREN SHANAHAN
Title or Position: CLINIC DIRECTOR
Credential: LMHC
Phone: 781-244-1950