Provider Demographics
NPI:1699822668
Name:NORTHEAST COMMUNITY CENTER FOR MENTAL HEALTH & MENTAL RETARDATION
Entity Type:Organization
Organization Name:NORTHEAST COMMUNITY CENTER FOR MENTAL HEALTH & MENTAL RETARDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:KAUFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-831-2800
Mailing Address - Street 1:4641 ROOSEVELT BLVD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19124-2343
Mailing Address - Country:US
Mailing Address - Phone:215-831-2800
Mailing Address - Fax:215-831-2929
Practice Address - Street 1:7226 CASTOR AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19149-1108
Practice Address - Country:US
Practice Address - Phone:215-742-7810
Practice Address - Fax:215-742-7017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA121890261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1000034170032Medicaid