1821560012 NPI number — PA MENTAL HEALTH

Table of content: (NPI 1821560012)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821560012 NPI number — PA MENTAL HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PA MENTAL HEALTH
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:
1821560012
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/28/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
204 ERIE ST STE 2FL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELIZABETH
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07206-1569
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
908-759-2370
Provider Business Mailing Address Fax Number:
908-469-5817

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
204 ERIE ST STE 2FL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELIZABETH
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07206-1569
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-759-2370
Provider Business Practice Location Address Fax Number:
908-469-5817
Provider Enumeration Date:
12/28/2018

Additional Information

Authorized Official

Authorized Official Last Name:
MATOS
Authorized Official First Name:
MIGUEL
Authorized Official Middle Name:
A
Authorized Official Title or Position:
LICENSED MENTAL HEALTH COUN CEO
Authorized Official Telephone Number:
908-759-2376

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1033399555 . This is a "NPI" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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