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General NPI Number Information
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NPI Number | 1083908388
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Entity Type | Organization
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Legal Business Name | MAIN LINE MENTAL HEALTH LLC
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Dates
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Enumeration Date | 06/03/2011
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Last Update Date | 06/03/2011
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Provider Practice Location Address
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Address Line | 349 LANCASTER AVE SUITE 103
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City | HAVERFORD
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State | PA
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Zip | 19041-1500
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Country | US
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Telephone | 610-945-5259
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Fax | 610-664-7061
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Provider Business Mailing Address
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Address Line | 349 WEST LANCASTER AVENUE SUITE 103
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City | HAVERFORD
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State | PA
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Zip | 19041-1500
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Country | US
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Telephone | 610-945-5259
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Fax | 610-664-7061
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Authorized Official
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Title or Position | SINGLE MEMBER LLC
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Name | DR. JONATHAN GERSHON SHACK
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Credential | MD
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Telephone | 610-945-5259
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | MD04514OL
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License Number State | PA
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