Healthcare Provider Details

I. General information

NPI: 1891992442
Provider Name (Legal Business Name): BUSTLETON MENTAL HEALTH INSTITUTE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9551 BUSTLETON AVE STE 2B
PHILADELPHIA PA
19115-3800
US

IV. Provider business mailing address

9551 BUSTLETON AVE STE 2B
PHILADELPHIA PA
19115-3800
US

V. Phone/Fax

Practice location:
  • Phone: 215-464-3838
  • Fax: 215-464-3899
Mailing address:
  • Phone: 215-464-3838
  • Fax: 215-464-3899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number129270
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number129270
License Number StatePA

VIII. Authorized Official

Name: MR. VLADIMIR PLATONOV
Title or Position: FACILITY DIRECTOR
Credential: M.D.
Phone: 215-464-3838