Provider Demographics
NPI:1346596798
Name:EELYSIUM BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:EELYSIUM BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VONTIA
Authorized Official - Middle Name:ANITA
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:267-266-2784
Mailing Address - Street 1:1441 W CAYUGA ST
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-1934
Mailing Address - Country:US
Mailing Address - Phone:267-266-2784
Mailing Address - Fax:
Practice Address - Street 1:1441 W CAYUGA ST
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19140-1934
Practice Address - Country:US
Practice Address - Phone:267-266-2784
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-02
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X, 253J00000X, 302F00000X, 3245S0500X, 343900000X
PA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No253J00000XAgenciesFoster Care Agency
No302F00000XManaged Care OrganizationsExclusive Provider Organization
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)