Provider Demographics
NPI:1972199032
Name:COMMUNITY COUNCIL FOR MENTAL HEALTH AND MENTAL RETARDATION I
Entity Type:Organization
Organization Name:COMMUNITY COUNCIL FOR MENTAL HEALTH AND MENTAL RETARDATION I
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BILLING
Authorized Official - Prefix:
Authorized Official - First Name:REKIYA
Authorized Official - Middle Name:
Authorized Official - Last Name:BELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-921-3713
Mailing Address - Street 1:4900 WYALUSING AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-5127
Mailing Address - Country:US
Mailing Address - Phone:215-473-7033
Mailing Address - Fax:215-827-5276
Practice Address - Street 1:4900 WYALUSING AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-5127
Practice Address - Country:US
Practice Address - Phone:215-921-3713
Practice Address - Fax:215-827-5276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA146020Medicaid