Provider Demographics
NPI:1023096864
Name:SOUTH BAY MENTAL HEALTH CENTER, INC.
Entity type:Organization
Organization Name:SOUTH BAY MENTAL HEALTH CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/COO
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:J
Authorized Official - Last Name:HART
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:508-324-0328
Mailing Address - Street 1:1115 WEST CHESTNUT STREET
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301
Mailing Address - Country:US
Mailing Address - Phone:508-521-2200
Mailing Address - Fax:508-584-2227
Practice Address - Street 1:1115 WEST CHESTNUT STREET
Practice Address - Street 2:SUITE 202
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301
Practice Address - Country:US
Practice Address - Phone:508-521-2200
Practice Address - Fax:508-584-2227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-03
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4222261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1311964Medicaid
MA1309226Medicaid
MA1310003Medicaid
MA1311093Medicaid
MA1312472Medicaid
MA1309056Medicaid
MA1316478Medicaid
MA1309218Medicaid
MA1312065Medicaid
MA1309994Medicaid
MA1300423Medicaid
MA1309137Medicaid
MA1310976Medicaid
MA1309196Medicaid
MA1319779Medicaid
MA1312065Medicaid
MA1309218Medicaid