Provider Demographics
NPI:1790092088
Name:SOUTH BAY MENTAL HEALTH CENTER
Entity Type:Organization
Organization Name:SOUTH BAY MENTAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TRAUMA THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PROVENCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-943-3773
Mailing Address - Street 1:148 WARREN ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01852-2208
Mailing Address - Country:US
Mailing Address - Phone:978-452-1736
Mailing Address - Fax:
Practice Address - Street 1:148 WARREN ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-2208
Practice Address - Country:US
Practice Address - Phone:978-452-1736
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health