Provider Demographics
NPI:1225693328
Name:NORTHEAST COMMUNITY CENTER FOR MENTAL HEALTH-MENTAL RETARDATION INC.
Entity Type:Organization
Organization Name:NORTHEAST COMMUNITY CENTER FOR MENTAL HEALTH-MENTAL RETARDATION INC.
Other - Org Name:NORTHEAST COMMUNITY CENTER FOR BEHAVIORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DEPUTY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:GUSCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-831-2826
Mailing Address - Street 1:4641 ROOSEVELT BLVD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19124-2343
Mailing Address - Country:US
Mailing Address - Phone:215-831-2836
Mailing Address - Fax:
Practice Address - Street 1:4371 WALN ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-4010
Practice Address - Country:US
Practice Address - Phone:215-831-2826
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-03
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health