Healthcare Provider Details

I. General information

NPI: 1639299167
Provider Name (Legal Business Name): TREE OF LIFE PROFESSIONAL BEHAVORIAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 01/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7048 CASTOR AVE
PHILADELPHIA PA
19149-1713
US

IV. Provider business mailing address

7048 CASTOR AVE
PHILADELPHIA PA
19149-1713
US

V. Phone/Fax

Practice location:
  • Phone: 215-533-5433
  • Fax: 215-533-5432
Mailing address:
  • Phone: 215-533-5433
  • Fax: 215-533-5432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number132210
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number132210
License Number StatePA

VIII. Authorized Official

Name: MS. ADA L TULEJA
Title or Position: CEO
Credential: MSW
Phone: 215-533-5433