Basic Information
Provider Information | |||||||||
NPI: | 1578685624 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CENTRALIZED COMPREHENSIVE HUMAN SERVICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | JOHN F KENNEDY BEHAVIORAL HEALTH CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 112 N BROAD ST | ||||||||
Address2: |   | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191021510 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2155680860 | ||||||||
FaxNumber: | 2155680769 | ||||||||
Practice Location | |||||||||
Address1: | 321 W GIRARD AVE | ||||||||
Address2: |   | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191231531 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2155680622 | ||||||||
FaxNumber: | 2155680769 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/06/2007 | ||||||||
LastUpdateDate: | 03/16/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | YOUNG | ||||||||
AuthorizedOfficialFirstName: | ALICE | ||||||||
AuthorizedOfficialMiddleName: | G | ||||||||
AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
AuthorizedOfficialTelephone: | 2155680860 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MBA | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 122000 | PA | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 1000034530015 | 05 | PA |   | MEDICAID |