1568740611 NPI number — COMMUNITY COUNCIL FOR MENTAL HEALTH AND MENTAL RETARDATION

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 1568740611 NPI number — COMMUNITY COUNCIL FOR MENTAL HEALTH AND MENTAL RETARDATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY COUNCIL FOR MENTAL HEALTH AND MENTAL RETARDATION
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:
1568740611
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4900 WYALUSING AVE
Provider Second Line Business Mailing Address:
MAIN BUILDING
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19131-5127
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-473-7033
Provider Business Mailing Address Fax Number:
215-827-5276

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
714 MARKET ST
Provider Second Line Business Practice Location Address:
5TH FLOOR
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19106-2326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-473-7033
Provider Business Practice Location Address Fax Number:
215-827-5276
Provider Enumeration Date:
07/22/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BELL
Authorized Official First Name:
REKIYAB
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF BILLING
Authorized Official Telephone Number:
215-473-7033

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  121630 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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