1083110605 NPI number — AVIVA MENTAL HEALTH SERVICES INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083110605 NPI number — AVIVA MENTAL HEALTH SERVICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AVIVA MENTAL HEALTH SERVICES INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083110605
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/28/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
320 MACDADE BLVD STE 205
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLLINGDALE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19023-1926
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-522-4506
Provider Business Mailing Address Fax Number:
610-522-4508

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
320 MACDADE BLVD
Provider Second Line Business Practice Location Address:
SUITE #205
Provider Business Practice Location Address City Name:
COLLINGDALE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19023
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-522-4506
Provider Business Practice Location Address Fax Number:
610-522-4507
Provider Enumeration Date:
04/03/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CHARLES
Authorized Official First Name:
SUSMARIA
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINICAL DIRECTOR
Authorized Official Telephone Number:
610-522-4506

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  143750 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: 143750 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: 143750 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC2200X , with the licence number: 143750 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X , with the licence number: 143750 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 163WP0808X , with the licence number: 143750 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0802X , with the licence number: 143750 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0804X , with the licence number: 143650 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X , with the licence number: 143750 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QM0850X , with the licence number: 143750 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0850X , with the licence number: 144120 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0855X , with the licence number: 143750 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0405X , with the licence number: 143750 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 143750 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 144120 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".