Organization
MAIN LINE MENTAL HEALTH LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JONATHAN GERSHON SHACK MD (SINGLE MEMBER LLC)
(610) 945-5259
Entity
Organization
Contact information
Practice address
349 LANCASTER AVE, SUITE 103, HAVERFORD, PA 19041-1500
(610) 945-5259
(610) 664-7061
Mailing address
349 WEST LANCASTER AVENUE, SUITE 103, HAVERFORD, PA 19041-1500
(610) 945-5259
(610) 664-7061
Taxonomy
Speciality
Code
Description
License number
State
2084P0800X
Psychiatry Physician
Primary
MD04514OL
PA
Other
Enumeration date
06/03/2011
Last updated
06/03/2011
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