=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659658938
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY BEHAVIORAL AND MENTAL HEALTH CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2011
-----------------------------------------------------
Last Update Date | 11/14/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3040 KENSINGTON AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19134-2416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-439-0976
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3040 KENSINGTON AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19134-2416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-439-0976
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR SUPERVISOR
-----------------------------------------------------
Name | YASSER ANTONIO ESPINAL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 215-439-0976
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------