Healthcare Provider Details

I. General information

NPI: 1215696430
Provider Name (Legal Business Name): AVIVA MENTAL HEALTH SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2021
Last Update Date: 12/15/2021
Certification Date: 12/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 MACDADE BLVD STE 205
COLLINGDALE PA
19023-1926
US

IV. Provider business mailing address

320 MACDADE BLVD STE 205
COLLINGDALE PA
19023-1926
US

V. Phone/Fax

Practice location:
  • Phone: 610-522-4506
  • Fax: 610-522-4508
Mailing address:
  • Phone: 610-522-4506
  • Fax: 610-522-4508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1034994870001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name: SUSMARIA CHARLES
Title or Position: DIRECTOR
Credential:
Phone: 610-522-4506