Provider Demographics
NPI:1639299167
Name:TREE OF LIFE PROFESSIONAL BEHAVORIAL HEALTH SERVICES
Entity Type:Organization
Organization Name:TREE OF LIFE PROFESSIONAL BEHAVORIAL HEALTH SERVICES
Other - Org Name:TREE OF LIFE BEHAVIORAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:ADA
Authorized Official - Middle Name:L
Authorized Official - Last Name:TULEJA
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:215-533-5433
Mailing Address - Street 1:7048 CASTOR AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19149-1713
Mailing Address - Country:US
Mailing Address - Phone:215-533-5433
Mailing Address - Fax:215-533-5432
Practice Address - Street 1:7048 CASTOR AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19149-1713
Practice Address - Country:US
Practice Address - Phone:215-533-5433
Practice Address - Fax:215-533-5432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA132210261QM0801X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1022413650001Medicaid