Healthcare Provider Details

I. General information

NPI: 1528171790
Provider Name (Legal Business Name): DR WARREN E SMITH COMMUNITY MENTAL HEALTH MENTAL RETARDATION & SUBSTAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 WINDRIM AVENUE
PHILADELPHIA PA
19141-2710
US

IV. Provider business mailing address

1315 WINDRIM AVENUE DR WARREN E SMITH HEALTH CENTERS
PHILADELPHIA PA
19141-2710
US

V. Phone/Fax

Practice location:
  • Phone: 215-456-2611
  • Fax: 215-456-2729
Mailing address:
  • Phone: 215-456-2611
  • Fax: 215-456-2729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number185300
License Number StatePA

VIII. Authorized Official

Name: KENNETH GLASS
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: PHD
Phone: 267-256-0636