Provider Demographics
NPI:1083908388
Name:MAIN LINE MENTAL HEALTH LLC
Entity Type:Organization
Organization Name:MAIN LINE MENTAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SINGLE MEMBER LLC
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:GERSHON
Authorized Official - Last Name:SHACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-945-5259
Mailing Address - Street 1:349 WEST LANCASTER AVENUE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:HAVERFORD
Mailing Address - State:PA
Mailing Address - Zip Code:19041-1500
Mailing Address - Country:US
Mailing Address - Phone:610-945-5259
Mailing Address - Fax:610-664-7061
Practice Address - Street 1:349 LANCASTER AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:HAVERFORD
Practice Address - State:PA
Practice Address - Zip Code:19041-1500
Practice Address - Country:US
Practice Address - Phone:610-945-5259
Practice Address - Fax:610-664-7061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-03
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD04514OL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty