Provider Demographics
NPI:1891974929
Name:WEST PHILADELPHIA COMMUNITY MENTAL HEALTH CONSORTIUM, INC.
Entity Type:Organization
Organization Name:WEST PHILADELPHIA COMMUNITY MENTAL HEALTH CONSORTIUM, INC.
Other - Org Name:THE CONSORTIUM INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:215-596-8100
Mailing Address - Street 1:3801 MARKET ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-3153
Mailing Address - Country:US
Mailing Address - Phone:215-596-8100
Mailing Address - Fax:215-382-4405
Practice Address - Street 1:5429 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19139-3300
Practice Address - Country:US
Practice Address - Phone:215-596-8100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-25
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1007155230082251S00000X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100715523 0082Medicaid