Provider Demographics
NPI:1922672005
Name:ITS MINE MOVEMENT, INC
Entity Type:Organization
Organization Name:ITS MINE MOVEMENT, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CAMILLA
Authorized Official - Middle Name:AMINAH
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-766-6060
Mailing Address - Street 1:701 E CATHEDRAL RD STE 45-1395
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-2128
Mailing Address - Country:US
Mailing Address - Phone:267-766-6060
Mailing Address - Fax:215-258-8588
Practice Address - Street 1:701 E CATHEDRAL RD STE 45-1395
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-2128
Practice Address - Country:US
Practice Address - Phone:267-532-4494
Practice Address - Fax:267-534-4497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103965593Medicaid