Basic Information
| Provider Information | |||||||||
| NPI: | 1003914466 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE MENTAL HEALTH CTR FOR SOUTHERN NEW HAMPSHIRE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CENTER FOR LIFE MANAGEMENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 TSIENNETO RD | ||||||||
| Address2: | |||||||||
| City: | DERRY | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034341577 | ||||||||
| FaxNumber: | 6034343101 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 TSIENNETO RD | ||||||||
| Address2: | |||||||||
| City: | DERRY | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034341577 | ||||||||
| FaxNumber: | 6034343101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 05/13/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TOPO | ||||||||
| AuthorizedOfficialFirstName: | VIC | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 6039650722 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 81263577 | 05 | NH | MEDICAID |