Healthcare Provider Details

I. General information

NPI: 1639572779
Provider Name (Legal Business Name): SOUTH SHORE MENTAL HEALTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2014
Last Update Date: 10/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 MOON ISLAND RD
SQUANTUM MA
02171-1034
US

IV. Provider business mailing address

500 VICTORY ROAD
QUINCY MA
02171-3139
US

V. Phone/Fax

Practice location:
  • Phone: 617-847-1950
  • Fax: 617-786-9894
Mailing address:
  • Phone: 617-847-1950
  • Fax: 617-786-9894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number459
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierEI0013
Identifier TypeOTHER
Identifier State
Identifier IssuerBLUE CROSS

VIII. Authorized Official

Name: STEPHEN WOJCIK
Title or Position: EXECUTIVE VICE PRESIDENT/TREASURER
Credential:
Phone: 617-847-1950