Healthcare Provider Details

I. General information

NPI: 1346473196
Provider Name (Legal Business Name): NORTHEAST BEHAVIORAL MEDICINE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2009
Last Update Date: 06/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6800 CASTOR AVE SUITE D
PHILADELPHIA PA
19149-2100
US

IV. Provider business mailing address

6800 CASTOR AVE SUITE D
PHILADELPHIA PA
19149-2100
US

V. Phone/Fax

Practice location:
  • Phone: 215-904-8748
  • Fax: 215-904-8691
Mailing address:
  • Phone: 215-904-8748
  • Fax: 215-904-6891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MR. RICK F NELSON JR.
Title or Position: PROVIDER RELATIONS
Credential:
Phone: 215-904-8748