Provider Demographics
NPI:1598167553
Name:FORENSIC MENTAL HEALTH SERVICE, LLC
Entity Type:Organization
Organization Name:FORENSIC MENTAL HEALTH SERVICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:215-514-1170
Mailing Address - Street 1:1241 VINE ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-1111
Mailing Address - Country:US
Mailing Address - Phone:215-514-1170
Mailing Address - Fax:215-405-2108
Practice Address - Street 1:1241 VINE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-1111
Practice Address - Country:US
Practice Address - Phone:215-514-1170
Practice Address - Fax:215-405-2108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-22
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPA006981103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty