Basic Information
| Provider Information | |||||||||
| NPI: | 1265996938 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DEVEREUX FOUNDATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 HENRY AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191291141 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 3300 HENRY AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191291141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2158646666 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2019 | ||||||||
| LastUpdateDate: | 01/28/2019 | ||||||||
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| AuthorizedOfficialLastName: | MCLAUGHLIN | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6104221463 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 100001913 | 05 | PA | MEDICAID |