Provider Demographics
NPI:1669988291
Name:SOUTH SHORE RECOVERY HOME
Entity type:Organization
Organization Name:SOUTH SHORE RECOVERY HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXEC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:MONAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LADAC I
Authorized Official - Phone:617-773-7023
Mailing Address - Street 1:10 DYSART ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-6702
Mailing Address - Country:US
Mailing Address - Phone:617-773-7023
Mailing Address - Fax:167-328-3799
Practice Address - Street 1:10 DYSART ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-6702
Practice Address - Country:US
Practice Address - Phone:617-773-7023
Practice Address - Fax:167-328-3799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-19
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0207251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health