Healthcare Provider Details

I. General information

NPI: 1770841777
Provider Name (Legal Business Name): SOUTH BAY MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2012
Last Update Date: 04/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 PINNACLE ST
HOOKSETT NH
03106-1535
US

IV. Provider business mailing address

26 PINNACLE ST
HOOKSETT NH
03106-1535
US

V. Phone/Fax

Practice location:
  • Phone: 603-365-1029
  • Fax:
Mailing address:
  • Phone: 603-365-1029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number06CHA84211
License Number StateNH

VIII. Authorized Official

Name: MRS. AMANDA EILEEN CINCEVICH
Title or Position: FAMILY SERVICES PROVIDER
Credential: M.A.
Phone: 603-365-1029