Provider Demographics
NPI:1306907704
Name:NORTHEAST COMMUNITY CENTER FOR MENTAL HEALTH-MENTAL RETARDATION I
Entity type:Organization
Organization Name:NORTHEAST COMMUNITY CENTER FOR MENTAL HEALTH-MENTAL RETARDATION I
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:COMO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-831-2800
Mailing Address - Street 1:4641 ROOSEVELT BLVD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19124-2343
Mailing Address - Country:US
Mailing Address - Phone:215-831-2800
Mailing Address - Fax:215-831-2929
Practice Address - Street 1:4641 ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-2343
Practice Address - Country:US
Practice Address - Phone:215-831-2800
Practice Address - Fax:215-831-2929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA121890261QM0855X, 261QM0850X, 261QM0855X, 261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA769146OtherMEDICARE PTAN
PA1000034170051Medicaid
PA169773OtherMEDICARE PTAN
PA769146OtherMEDICARE PTAN
PA169773OtherMEDICARE PTAN