Provider Demographics
NPI:1720288913
Name:TRANSITION PHASE III
Entity Type:Organization
Organization Name:TRANSITION PHASE III
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO GROUP ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JO
Authorized Official - Middle Name:
Authorized Official - Last Name:BENAIT
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:215-878-3052
Mailing Address - Street 1:3900 CITY AVENUE
Mailing Address - Street 2:MADISON BLDG SUITE 1207
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-0000
Mailing Address - Country:US
Mailing Address - Phone:215-878-3052
Mailing Address - Fax:215-878-3532
Practice Address - Street 1:3900 CITY AVE
Practice Address - Street 2:MADISON BLDG SUITE 1207
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-2908
Practice Address - Country:US
Practice Address - Phone:215-878-3052
Practice Address - Fax:215-878-3532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1019569460001Medicaid