Provider Demographics
NPI:1497032957
Name:SOUTHBAY MENTAL HEALTH
Entity Type:Organization
Organization Name:SOUTHBAY MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:631-219-1131
Mailing Address - Street 1:13 PLEASANT ST
Mailing Address - Street 2:APT.1
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-3210
Mailing Address - Country:US
Mailing Address - Phone:631-219-1131
Mailing Address - Fax:
Practice Address - Street 1:15 UNION ST
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01840-1866
Practice Address - Country:US
Practice Address - Phone:978-688-5222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-12
Last Update Date:2011-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA217636251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health