MEDICARE: NORTHEAST COMMUNITY CENTER FOR MENTAL HEALTH & MENTAL RETARDATION

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	261QM0850X	Adult Mental Health Clinic/Center	121890	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1427110030
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHEAST COMMUNITY CENTER FOR MENTAL HEALTH & MENTAL RETARDATION

Provider Business Mailing Address
First Line	:	4641 ROOSEVELT BLVD
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19124-2343
Country	:	US
Telephone Number	:	215-831-2800
Fax Number	:	215-831-2929

Provider Business Practice Location Address
First Line	:	1527 OVERINGTON ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19124-5831
Country	:	US
Telephone Number	:	215-831-2900
Fax Number	:	215-831-2983

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	HOWARD J KAUFMAN
Credential	:
Telephone Number	:	215-831-2800

Provider Enumeration Date	:	12/14/2006
Last Update Date	:	08/22/2020

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