Basic Information
| Provider Information | |||||||||
| NPI: | 1760895981 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDREN'S ACUTE PARTIAL PROGRAM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 WISSAHICKON AVE | ||||||||
| Address2: | SUITE 126 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191444248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159510300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 801 N 48TH ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191391854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2153073210 | ||||||||
| FaxNumber: | 2153073581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2014 | ||||||||
| LastUpdateDate: | 06/18/2014 | ||||||||
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| AuthorizedOfficialLastName: | ROTH | ||||||||
| AuthorizedOfficialFirstName: | DYANN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2159510300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RESOURCES FOR HUMAN DEVELOPMENT, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 100001708 | 05 | PA | MEDICAID |