Provider Demographics
NPI:1013129709
Name:INTERVENTIVE CARE CRISIS MANAGEMENT NETWORK
Entity Type:Organization
Organization Name:INTERVENTIVE CARE CRISIS MANAGEMENT NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:YATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-994-7752
Mailing Address - Street 1:3800 N BROAD ST FL 2
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-3610
Mailing Address - Country:US
Mailing Address - Phone:215-225-5566
Mailing Address - Fax:215-949-3483
Practice Address - Street 1:3800 NORTH BROAD STREET
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140
Practice Address - Country:US
Practice Address - Phone:215-225-5566
Practice Address - Fax:215-949-3483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA102930251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016910490001OtherPROMISE MAID