Healthcare Provider Details

I. General information

NPI: 1508077496
Provider Name (Legal Business Name): SOUTH BAY MENTAL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

332 MAIN ST 30
WORCESTER MA
01608-1517
US

IV. Provider business mailing address

14 MENDON ST
WORCESTER MA
01604-4804
US

V. Phone/Fax

Practice location:
  • Phone: 508-752-3969
  • Fax: 508-725-3967
Mailing address:
  • Phone: 508-847-0480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MS. ALYSSA MARIE JONIKAS
Title or Position: CASE MANAGER
Credential: BA
Phone: 508-752-3936