Healthcare Provider Details

I. General information

NPI: 1023231370
Provider Name (Legal Business Name): COMMUNITY COUNCIL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 04/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 W ONTARIO ST
PHILADELPHIA PA
19140-5012
US

IV. Provider business mailing address

4900 WYALUSING AVE
PHILADELPHIA PA
19131-5127
US

V. Phone/Fax

Practice location:
  • Phone: 215-228-4412
  • Fax: 215-227-8778
Mailing address:
  • Phone: 215-473-7033
  • Fax: 215-933-6926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number121630
License Number StatePA

VIII. Authorized Official

Name: JAMES PAIGE
Title or Position: CHIEF INFORMATION OFFICER
Credential:
Phone: 215-473-7033