Provider Demographics
NPI:1033294558
Name:SOUTH BAY MENTAL HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:SOUTH BAY MENTAL HEALTH CENTER, INC.
Other - Org Name:SOUTH BAY COMMUNITY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/COO
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:J
Authorized Official - Last Name:HART
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:508-324-0328
Mailing Address - Street 1:1115 WEST CHESTNUT STREET SUITE 202
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301
Mailing Address - Country:US
Mailing Address - Phone:508-521-2200
Mailing Address - Fax:508-584-2227
Practice Address - Street 1:1115 WEST CHESTNUT STREET SUITE 202
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301
Practice Address - Country:US
Practice Address - Phone:508-521-2200
Practice Address - Fax:508-584-2227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4222261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1803034Medicaid
MA1803395Medicaid
MA1803514Medicaid