MEDICARE: SOUTH BAY MENTAL HEALTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1710350913
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH BAY MENTAL HEALTH

Provider Business Mailing Address
First Line	:	670 ROUTE 6A
Second Line	:
City	:	EAST SANDWICH
State	:	MA
Zip	:	02537-1436
Country	:	US
Telephone Number	:	508-367-4309
Fax Number	:	508-746-8429

Provider Business Practice Location Address
First Line	:	670 ROUTE 6A
Second Line	:
City	:	EAST SANDWICH
State	:	MA
Zip	:	02537-1436
Country	:	US
Telephone Number	:	508-367-4309
Fax Number	:	508-746-8429

Authorized Official
Title or Position	:	SITE ADMINISTRATOR
Name	:	DEBRA KELLY
Credential	:	LMHC
Telephone Number	:	508-830-0000

Provider Enumeration Date	:	11/10/2015
Last Update Date	:	11/10/2015

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