Basic Information
| Provider Information | |||||||||
| NPI: | 1902818826 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH SHORE MENTAL HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 VICTORY RD | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021713139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6178471950 | ||||||||
| FaxNumber: | 6177869896 | ||||||||
| Practice Location | |||||||||
| Address1: | 310 BARNSTABLE RD | ||||||||
| Address2: | |||||||||
| City: | HYANNIS | ||||||||
| State: | MA | ||||||||
| PostalCode: | 026012902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088620514 | ||||||||
| FaxNumber: | 5088629184 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | FERNANDEZ | ||||||||
| AuthorizedOfficialFirstName: | LU | ||||||||
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| AuthorizedOfficialTitleorPosition: | SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 6178471926 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 305R00000X | 1025460 | MA | Y | Managed Care Organizations | Preferred Provider Organization |
No ID Information.