Provider Demographics
NPI:1215578570
Name:CHINNAIYAN MATHIAS, JOHN STANLEY RAJ
Entity Type:Individual
Prefix:
First Name:JOHN STANLEY RAJ
Middle Name:
Last Name:CHINNAIYAN MATHIAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 BETHLEHEM PIKE
Mailing Address - Street 2:
Mailing Address - City:COLMAR
Mailing Address - State:PA
Mailing Address - Zip Code:18915-9790
Mailing Address - Country:US
Mailing Address - Phone:215-997-2000
Mailing Address - Fax:
Practice Address - Street 1:6930 MARKET ST
Practice Address - Street 2:
Practice Address - City:UPPER DARBY
Practice Address - State:PA
Practice Address - Zip Code:19082-2308
Practice Address - Country:US
Practice Address - Phone:484-469-4319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH001686101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health