Provider Demographics
NPI:1114046638
Name:WEST PHILADELPHIA COMMUNITY MH CONSORTIUM, INC.
Entity Type:Organization
Organization Name:WEST PHILADELPHIA COMMUNITY MH CONSORTIUM, INC.
Other - Org Name:THE CONSORTIUM INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:F
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:215-596-8100
Mailing Address - Street 1:3801 MARKET ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-3153
Mailing Address - Country:US
Mailing Address - Phone:215-596-8100
Mailing Address - Fax:215-382-4405
Practice Address - Street 1:137 S 58TH ST
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19139-3134
Practice Address - Country:US
Practice Address - Phone:215-596-8100
Practice Address - Fax:215-382-4405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007155230020Medicaid