MEDICARE: DIVERSIFIED SUPPORTIVE SERVICES

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	251C00000X	Developmentally Disabled Services Day Training Agency	383203	PA

General Provider Information

NPI Number	:	1942461579
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVERSIFIED SUPPORTIVE SERVICES

Provider Business Mailing Address
First Line	:	2824 COTTMAN AVE
Second Line	:	SUITE 1
City	:	PHILADELPHIA
State	:	PA
Zip	:	19149-1400
Country	:	US
Telephone Number	:	215-673-2778
Fax Number	:	215-673-3451

Provider Business Practice Location Address
First Line	:	2824 COTTMAN AVE
Second Line	:	SUITE 1
City	:	PHILADELPHIA
State	:	PA
Zip	:	19149-1400
Country	:	US
Telephone Number	:	215-673-2778
Fax Number	:	215-673-3451

Authorized Official
Title or Position	:	CO-MANAGER
Name	:	MS. RASHEEN HALIMAH BEARD
Credential	:
Telephone Number	:	215-673-2778

Provider Enumeration Date	:	06/17/2008
Last Update Date	:	06/17/2008

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Directions to “DIVERSIFIED SUPPORTIVE SERVICES ” Practice Location

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