=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639299167
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TREE OF LIFE PROFESSIONAL BEHAVORIAL HEALTH SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2007
-----------------------------------------------------
Last Update Date | 01/28/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7048 CASTOR AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19149-1713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-533-5433
-----------------------------------------------------
Fax | 215-533-5432
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7048 CASTOR AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19149-1713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-533-5433
-----------------------------------------------------
Fax | 215-533-5432
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MS. ADA L TULEJA
-----------------------------------------------------
Credential | MSW
-----------------------------------------------------
Telephone | 215-533-5433
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number | 132210
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 132210
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------