Provider Demographics
| NPI: | 1134482409 |
|---|---|
| Name: | SPECTRA SUPPORT SERVICES, LLC |
| Entity type: | Organization |
| Organization Name: | SPECTRA SUPPORT SERVICES, LLC |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | DIRECTOR/ CO-OWNER |
| Authorized Official - Prefix: | MRS |
| Authorized Official - First Name: | MALEITA |
| Authorized Official - Middle Name: | MARGUERITE |
| Authorized Official - Last Name: | OLSON |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | LCSW |
| Authorized Official - Phone: | 484-450-6476 |
| Mailing Address - Street 1: | 390 REED RD FL 1 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | BROOMALL |
| Mailing Address - State: | PA |
| Mailing Address - Zip Code: | 19008-4008 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 484-450-6476 |
| Mailing Address - Fax: | 484-224-3398 |
| Practice Address - Street 1: | 390 REED RD FL 1 |
| Practice Address - Street 2: | |
| Practice Address - City: | BROOMALL |
| Practice Address - State: | PA |
| Practice Address - Zip Code: | 19008-4008 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 484-450-6476 |
| Practice Address - Fax: | 484-450-6476 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2012-06-20 |
| Last Update Date: | 2020-04-02 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| 101YM0800X, 101YP2500X, 104100000X, 106H00000X, 225A00000X, 251S00000X, 261QM1300X, 1041C0700X, 261QM1300X, 251S00000X | ||
| PA | BH000073 | 103K00000X, 103K00000X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
| No | 101YM0800X | Behavioral Health & Social Service Providers | Counselor | Mental Health | Group - Multi-Specialty |
| No | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional | Group - Multi-Specialty |
| No | 103K00000X | Behavioral Health & Social Service Providers | Behavior Analyst | Group - Multi-Specialty | |
| No | 104100000X | Behavioral Health & Social Service Providers | Social Worker | Group - Multi-Specialty | |
| No | 106H00000X | Behavioral Health & Social Service Providers | Marriage & Family Therapist | Group - Multi-Specialty | |
| No | 225A00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Music Therapist | Group - Multi-Specialty | |
| No | 251S00000X | Agencies | Community/Behavioral Health | Group - Multi-Specialty | |
| No | 261QM1300X | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| PA | 1027817150022 | Medicaid | |
| PA | 1027817150023 | Medicaid | |
| PA | 1027817150024 | Medicaid | |
| PA | 1027817150019 | Medicaid | |
| PA | 1027817150021 | Medicaid | |
| PA | 1027817150020 | Medicaid | |
| PA | 1027817150023 | Medicaid | |
| PA | 10278171500008 | Medicaid | |
| PA | 1027817150016 | Medicaid | |
| PA | 1027817150024 | Medicaid | |
| PA | 10278171500009 | Medicaid | |
| PA | 1027817150014 | Medicaid | |
| PA | 1027817150015 | Medicaid | |
| PA | 1027817150021 | Medicaid | |
| PA | 10278171500012 | Medicaid | |
| PA | 1027817150020 | Medicaid | |
| PA | 10278171500011 | Medicaid |
