Organization
NOVA III
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DYANN M ROTH (CEO)
(215) 951-0300
Entity
Organization
Contact information
Practice address
1101 W. SPENCER ST, SUITE 406, PHILADELPHIA, PA 19141-3239
(215) 951-0300
Mailing address
4700 WISSAHICKON AVE, SUITE 126, PHILADELPHIA, PA 19144-4248
(215) 951-0300
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
—
—
261QR0405X
Substance Use Disorder Rehabilitation Clinic/Center
—
PA
320800000X
Mental Illness Community Based Residential Treatment Facility
—
PA
324500000X
Substance Abuse Rehabilitation Facility
—
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1000017080494
—
PA
Enumeration date
03/08/2007
Last updated
10/05/2015
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