Organization
NORTHEAST COMMUNITY CENTER FOR MENTAL HEALTH-MENTAL RETARDATION I
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DAVID COMO (EXECUTIVE DIRECTOR)
(215) 831-2800
Entity
Organization
Contact information
Practice address
4641 ROOSEVELT BLVD, PHILADELPHIA, PA 19124-2343
(215) 831-2800
(215) 831-2929
Mailing address
4641 ROOSEVELT BLVD, PHILADELPHIA, PA 19124-2343
(215) 831-2800
(215) 831-2929
Taxonomy
Speciality
Code
Description
License number
State
261QM0850X
Adult Mental Health Clinic/Center
Primary
121890
PA
261QM0855X
Adolescent and Children Mental Health Clinic/Center
121890
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1000034170051
—
PA
01
—
169773
MEDICARE PTAN
PA
01
—
769146
MEDICARE PTAN
PA
Enumeration date
12/12/2006
Last updated
07/09/2014
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