Healthcare Provider Details

I. General information

NPI: 1346596798
Provider Name (Legal Business Name): EELYSIUM BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2012
Last Update Date: 04/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 W CAYUGA ST
PHILA PA
19140-1934
US

IV. Provider business mailing address

1441 W CAYUGA ST
PHILA PA
19140-1934
US

V. Phone/Fax

Practice location:
  • Phone: 267-266-2784
  • Fax:
Mailing address:
  • Phone: 267-266-2784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: VONTIA ANITA JONES
Title or Position: OWNER/PRESIDENT
Credential: M.S
Phone: 267-266-2784