Provider Demographics
NPI:1922180538
Name:SO .SHORE MENTAL HEALTH
Entity Type:Organization
Organization Name:SO .SHORE MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE COORDIATOR
Authorized Official - Prefix:
Authorized Official - First Name:LU
Authorized Official - Middle Name:
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-741-1490
Mailing Address - Street 1:215 SANDWICH RD
Mailing Address - Street 2:
Mailing Address - City:WAREHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02571-1637
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:215 SANDWICH RD
Practice Address - Street 2:
Practice Address - City:WAREHAM
Practice Address - State:MA
Practice Address - Zip Code:02571-1637
Practice Address - Country:US
Practice Address - Phone:508-291-8425
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA105914101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPO3775Medicare ID - Type UnspecifiedMEDICARE