Provider Demographics
NPI:1205362399
Name:SOUTHBAY MENTAL HEALTH
Entity Type:Organization
Organization Name:SOUTHBAY MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:NOLDA
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:860-573-1300
Mailing Address - Street 1:83 PILGRIM DR
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-1910
Mailing Address - Country:US
Mailing Address - Phone:860-558-2637
Mailing Address - Fax:
Practice Address - Street 1:83 PILGRIM DR
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06095-1910
Practice Address - Country:US
Practice Address - Phone:860-558-2637
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-10
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001559252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency