Provider Demographics
NPI:1588365399
Name:PA MENTAL HEALTH PROFESSIONAL SRVCS LLC
Entity type:Organization
Organization Name:PA MENTAL HEALTH PROFESSIONAL SRVCS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:ANGEL
Authorized Official - Last Name:MATOS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:908-759-2376
Mailing Address - Street 1:410 BIRCH CT
Mailing Address - Street 2:
Mailing Address - City:NEW BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08901-2693
Mailing Address - Country:US
Mailing Address - Phone:908-759-2376
Mailing Address - Fax:
Practice Address - Street 1:410 BIRCH CT
Practice Address - Street 2:
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-2693
Practice Address - Country:US
Practice Address - Phone:908-759-2376
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-17
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1033399555Medicaid