Provider Demographics
NPI:1114044112
Name:BANCROFT NEUROHEALTH
Entity Type:Organization
Organization Name:BANCROFT NEUROHEALTH
Other - Org Name:THE WALKER MEMORIAL TRAINING CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:SENIOR DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:E
Authorized Official - Last Name:WILLIAMS-TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:MS STLDR
Authorized Official - Phone:610-747-0290
Mailing Address - Street 1:304 OLD LANCASTER RD
Mailing Address - Street 2:
Mailing Address - City:MERION STATION
Mailing Address - State:PA
Mailing Address - Zip Code:19066-1526
Mailing Address - Country:US
Mailing Address - Phone:610-747-0290
Mailing Address - Fax:610-747-0294
Practice Address - Street 1:105 4TH AVE
Practice Address - Street 2:
Practice Address - City:BROOMALL
Practice Address - State:PA
Practice Address - Zip Code:19008-2321
Practice Address - Country:US
Practice Address - Phone:610-356-1769
Practice Address - Fax:610-747-0294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA135180320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101112176-0037Medicaid