Healthcare Provider Details

I. General information

NPI: 1760974679
Provider Name (Legal Business Name): AVIVA MENTAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2018
Last Update Date: 06/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 S MACDADE BLVD # 105
COLLINGDALE PA
19023-1510
US

IV. Provider business mailing address

17 S MACDADE BLVD # 105
COLLINGDALE PA
19023-1510
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 Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number144120
License Number StatePA

VIII. Authorized Official

Name: MRS. SUSMARIA CHARLES
Title or Position: CLINICAL DIRECTOR
Credential: MHS;CPSS
Phone: 610-522-4506