Provider Demographics
NPI:1801472634
Name:MENTAL HEALTH SPECIALTY GROUP PA
Entity type:Organization
Organization Name:MENTAL HEALTH SPECIALTY GROUP PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED AGENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSH
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-205-7088
Mailing Address - Street 1:PO BOX 746878
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6878
Mailing Address - Country:US
Mailing Address - Phone:323-205-7088
Mailing Address - Fax:
Practice Address - Street 1:110 N CORCORAN ST FL 5
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27701-5015
Practice Address - Country:US
Practice Address - Phone:323-205-7088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-22
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Multi-Specialty