Provider Demographics
NPI:1265271522
Name:VICTORY BAY MENTAL HEALTH MA LLC
Entity type:Organization
Organization Name:VICTORY BAY MENTAL HEALTH MA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:MACCARELLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-440-7593
Mailing Address - Street 1:7 EVES DR STE 100
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-3196
Mailing Address - Country:US
Mailing Address - Phone:856-440-9573
Mailing Address - Fax:
Practice Address - Street 1:500 W CUMMINGS PARK
Practice Address - Street 2:SUITE 1700 AND 1800
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801
Practice Address - Country:US
Practice Address - Phone:856-440-9573
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-24
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)