Provider Demographics
NPI:1922321173
Name:DIVERSIFIED SUPPORTIVE SERVICES LLC
Entity Type:Organization
Organization Name:DIVERSIFIED SUPPORTIVE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:RASHEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BETHEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-673-2778
Mailing Address - Street 1:1714 MEMPHIS ST
Mailing Address - Street 2:SUITE C-8
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19125-2700
Mailing Address - Country:US
Mailing Address - Phone:215-673-2778
Mailing Address - Fax:215-673-3451
Practice Address - Street 1:1714 MEMPHIS ST
Practice Address - Street 2:SUITE C-8
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19125-2700
Practice Address - Country:US
Practice Address - Phone:215-673-2778
Practice Address - Fax:215-673-3451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-02
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA383203251B00000X
PA16723601251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251E00000XAgenciesHome Health