Provider Demographics
NPI:1265797252
Name:SOUTH BAY MENTAL HEALTH
Entity type:Organization
Organization Name:SOUTH BAY MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:HELEN
Authorized Official - Last Name:SANFORD
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:508-830-0000
Mailing Address - Street 1:50 ALDRIN RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-4827
Mailing Address - Country:US
Mailing Address - Phone:508-830-0000
Mailing Address - Fax:508-746-8429
Practice Address - Street 1:50 ALDRIN RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-4827
Practice Address - Country:US
Practice Address - Phone:508-830-0000
Practice Address - Fax:508-746-8429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-06
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1026901251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1026901OtherCOMMONWEALTH OF MASSACHUSETTS/ SOCIAL WORKER/ LICSW