Provider Demographics
NPI:1265862791
Name:THERESA M SMITH
Entity Type:Organization
Organization Name:THERESA M SMITH
Other - Org Name:SOUTH OF BOSTON HEALING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:A
Authorized Official - Last Name:PUOPOLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-583-9800
Mailing Address - Street 1:820 PEARL ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-4411
Mailing Address - Country:US
Mailing Address - Phone:508-583-9800
Mailing Address - Fax:508-583-9802
Practice Address - Street 1:820 PEARL ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-4411
Practice Address - Country:US
Practice Address - Phone:508-583-9800
Practice Address - Fax:508-583-9802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-19
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN/NP115563101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty