Organization
MAIN LINE MENTAL HEALTH LLC
Active
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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