Healthcare Provider Details

I. General information

NPI: 1801472634
Provider Name (Legal Business Name): MENTAL HEALTH SPECIALTY GROUP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2021
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 N CORCORAN ST FL 5
DURHAM NC
27701-5015
US

IV. Provider business mailing address

PO BOX 746878
ATLANTA GA
30374-6878
US

V. Phone/Fax

Practice location:
  • Phone: 323-205-7088
  • Fax: 866-277-9071
Mailing address:
  • Phone: 323-205-7088
  • Fax: 866-277-9071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: GABRIEL DIOP
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 617-823-6490