Basic Information
| Provider Information | |||||||||
| NPI: | 1255384723 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SBSC, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 246 WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | NEWTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024601689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172443322 | ||||||||
| FaxNumber: | 6172441827 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 LANCASTER ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041012418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077722133 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 06/13/2011 | ||||||||
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| AuthorizedOfficialLastName: | NAGER | ||||||||
| AuthorizedOfficialFirstName: | NANCY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 6172443322 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 163WP0808X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Psych/Mental Health | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 103TC0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 425620000 | 05 | ME | MEDICAID | 432125700 | 05 | ME | MEDICAID |