Provider Demographics
NPI:1902165285
Name:SOUTH BAY MENTAL HEALTH
Entity Type:Organization
Organization Name:SOUTH BAY MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPEUTIC MENTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:OSCAR
Authorized Official - Last Name:SUNESON
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:508-324-1060
Mailing Address - Street 1:1563 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02720-2983
Mailing Address - Country:US
Mailing Address - Phone:508-324-1060
Mailing Address - Fax:
Practice Address - Street 1:1563 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-2983
Practice Address - Country:US
Practice Address - Phone:508-324-1060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-08
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS47875271251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health