MEDICARE: COMMUNITY COUNCIL FOR MENTAL HEALTH & MENTAL RETARDATION INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1316579923
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY COUNCIL FOR MENTAL HEALTH & MENTAL RETARDATION INC.

Provider Business Mailing Address
First Line	:	4900 WYALUSING AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19131-5127
Country	:	US
Telephone Number	:	215-921-3713
Fax Number	:	215-827-5276

Provider Business Practice Location Address
First Line	:	1211 CHESTNUT ST FL 8
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19107-4103
Country	:	US
Telephone Number	:	267-514-3500
Fax Number	:	267-514-3783

Authorized Official
Title or Position	:	DIRECTOR OF BILLING
Name	:	REKIYA BELL
Credential	:
Telephone Number	:	215-921-3713

Provider Enumeration Date	:	02/11/2020
Last Update Date	:	08/14/2020

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