Provider Demographics
NPI:1891014783
Name:WEST PHILADELPHIA COMMUNITY MENTAL HEALTH CONSORTIUM
Entity Type:Organization
Organization Name:WEST PHILADELPHIA COMMUNITY MENTAL HEALTH CONSORTIUM
Other - Org Name:THE CONSOTIUM INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:F
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:215-596-8100
Mailing Address - Street 1:111 N 49TH ST
Mailing Address - Street 2:EARLY INTERVENTION PROGRAM
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19139-2718
Mailing Address - Country:US
Mailing Address - Phone:215-596-8100
Mailing Address - Fax:215-382-4405
Practice Address - Street 1:111 N 49TH ST
Practice Address - Street 2:EARLY INTERVENTION PROGRAM
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19139-2718
Practice Address - Country:US
Practice Address - Phone:215-596-8100
Practice Address - Fax:215-382-4405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-18
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007155230001Medicaid