Provider Demographics
NPI:1346790730
Name:SOUTH BAY CONNECT TREATMENT CENTER
Entity Type:Organization
Organization Name:SOUTH BAY CONNECT TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MACGOWAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:310-776-7406
Mailing Address - Street 1:916 N WESTERN AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-2435
Mailing Address - Country:US
Mailing Address - Phone:310-776-7406
Mailing Address - Fax:
Practice Address - Street 1:916 N WESTERN AVE STE 210
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-2407
Practice Address - Country:US
Practice Address - Phone:310-776-7406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21303101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1619157716OtherNPPES