Healthcare Provider Details

I. General information

NPI: 1871756486
Provider Name (Legal Business Name): WEST PHILADELPHIA COMMUNITY MENTAL HEALTH CONSORTIUM INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2008
Last Update Date: 07/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 PENNSYLVANIA AVE
PHILADELPHIA PA
19130-3832
US

IV. Provider business mailing address

3801 MARKET STREET 201
PHILADELPHIA PA
19104-3153
US

V. Phone/Fax

Practice location:
  • Phone: 215-596-8100
  • Fax: 215-382-4405
Mailing address:
  • Phone: 215-596-8100
  • Fax: 215-382-4405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN F WHITE JR.
Title or Position: PRESIDENT/CEO
Credential:
Phone: 215-596-8100