Provider Demographics
NPI:1518380591
Name:SALT SPECIAL NEEDS DM
Entity Type:Organization
Organization Name:SALT SPECIAL NEEDS DM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DYANN
Authorized Official - Middle Name:M
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-951-0300
Mailing Address - Street 1:4700 WISSAHICKON AVE
Mailing Address - Street 2:SUITE 126
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-4248
Mailing Address - Country:US
Mailing Address - Phone:215-951-0300
Mailing Address - Fax:
Practice Address - Street 1:507 W MANHEIM ST
Practice Address - Street 2:APT 507-01A
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19144-4863
Practice Address - Country:US
Practice Address - Phone:215-951-0300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RESOURCES FOR HUMAN DEVELOPMENT, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-01-28
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100001708Medicaid