=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215345301
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHEAST COMMUNITY CENTER FOR MENTAL HEALTH & MENTAL RETARDATION, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2014
-----------------------------------------------------
Last Update Date | 08/01/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4641 ROOSEVELT BLVD
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19124-2343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-831-2800
-----------------------------------------------------
Fax | 215-831-2929
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4641 ROOSEVELT BLVD
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19124-2343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-831-2800
-----------------------------------------------------
Fax | 215-831-2929
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | DAVID COMO
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 215-831-2800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------