Provider Demographics
NPI:1851480891
Name:SOUTH SHORE MENTAL HEALTH
Entity Type:Organization
Organization Name:SOUTH SHORE MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SELF
Authorized Official - Prefix:
Authorized Official - First Name:SONIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODEN-ALEXIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-323-0381
Mailing Address - Street 1:4820 SWANNS MILL DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-1492
Mailing Address - Country:US
Mailing Address - Phone:919-323-0381
Mailing Address - Fax:
Practice Address - Street 1:4820 SWANNS MILL DR
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-1492
Practice Address - Country:US
Practice Address - Phone:919-323-0381
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5736251K00000X
NC6748251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS014759Medicaid
MA=========Medicare UPIN
MAY 10241Medicare ID - Type UnspecifiedPROVIDERS NUMBER