Provider Demographics
NPI:1417051780
Name:SOUTH SHORE MENTAL HEALTH
Entity Type:Organization
Organization Name:SOUTH SHORE MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LU
Authorized Official - Middle Name:
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-847-1926
Mailing Address - Street 1:500 VICTORY RD
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02171-3139
Mailing Address - Country:US
Mailing Address - Phone:617-847-1926
Mailing Address - Fax:
Practice Address - Street 1:500 VICTORY RD
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02171-3139
Practice Address - Country:US
Practice Address - Phone:617-847-1926
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1025460305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization