Provider Demographics
NPI:1336634914
Name:AVIVA MENTAL HEALTH SERVICES
Entity Type:Organization
Organization Name:AVIVA MENTAL HEALTH SERVICES
Other - Org Name:AVIVA MENTAL HEALTH SERVICES INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSMARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHARLES
Authorized Official - Suffix:
Authorized Official - Credentials:MHS;CPSS
Authorized Official - Phone:610-522-4506
Mailing Address - Street 1:PO BOX 102
Mailing Address - Street 2:
Mailing Address - City:UPPER DARBY
Mailing Address - State:PA
Mailing Address - Zip Code:19082-0102
Mailing Address - Country:US
Mailing Address - Phone:610-522-4506
Mailing Address - Fax:610-522-4508
Practice Address - Street 1:320 MACDADE BLVD
Practice Address - Street 2:
Practice Address - City:COLLINGDALE
Practice Address - State:PA
Practice Address - Zip Code:19023-1927
Practice Address - Country:US
Practice Address - Phone:610-522-4506
Practice Address - Fax:610-522-4508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-26
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA237103324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA823017837Medicaid