Provider Demographics
NPI:1083110605
Name:AVIVA MENTAL HEALTH SERVICES INC
Entity type:Organization
Organization Name:AVIVA MENTAL HEALTH SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSMARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHARLES
Authorized Official - Suffix:
Authorized Official - Credentials:MHS;CPSS
Authorized Official - Phone:610-522-4506
Mailing Address - Street 1:320 MACDADE BLVD STE 205
Mailing Address - Street 2:
Mailing Address - City:COLLINGDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19023-1926
Mailing Address - Country:US
Mailing Address - Phone:610-522-4506
Mailing Address - Fax:610-522-4508
Practice Address - Street 1:320 MACDADE BLVD
Practice Address - Street 2:SUITE #205
Practice Address - City:COLLINGDALE
Practice Address - State:PA
Practice Address - Zip Code:19023
Practice Address - Country:US
Practice Address - Phone:610-522-4506
Practice Address - Fax:610-522-4507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-03
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA143750261QM0850X, 101YA0400X, 101YM0800X, 103T00000X, 103TC2200X, 106H00000X, 163WP0808X, 2084P0802X, 261QM0855X, 261QR0405X, 261QM0801X
PA144120261QM0850X
PA1436502084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Multi-Specialty
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Multi-Specialty
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA143750Medicaid
PA144120Medicaid