Healthcare Provider Details

I. General information

NPI: 1255592044
Provider Name (Legal Business Name): SOUTH COUNTY BEHAVIORAL MEDICINE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2008
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 SALT POND RD UNIT D3
WAKEFIELD RI
02879-4314
US

IV. Provider business mailing address

PO BOX 360
WAKEFIELD RI
02880-0360
US

V. Phone/Fax

Practice location:
  • Phone: 401-789-2306
  • Fax:
Mailing address:
  • Phone: 401-789-2306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: JON KIMPTON
Title or Position: OWNER/ PRESIDENT
Credential:
Phone: 401-789-2306