=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508179292
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BUILDING TO LIFE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2010
-----------------------------------------------------
Last Update Date | 07/22/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4728 OXFORD AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19124-5835
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-500-9425
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7419 BARCLAY RD
-----------------------------------------------------
City | CHELTENHAM
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19012-1302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-500-9425
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CASE MANAGER
-----------------------------------------------------
Name | ANITA DAVIS
-----------------------------------------------------
Credential | BS HUMAN SERVICES
-----------------------------------------------------
Telephone | 215-500-9425
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------