Basic Information
Provider Information | |||||||||
NPI: | 1821096793 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CENTER FOR BEHAVIORAL HEALTH HA, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6185 PASEO DEL NORTE | ||||||||
Address2: | SUITE 200 | ||||||||
City: | CARLSBAD | ||||||||
State: | CA | ||||||||
PostalCode: | 92011 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8552592288 | ||||||||
FaxNumber: | 8775520439 | ||||||||
Practice Location | |||||||||
Address1: | 1914 MERCER AVE | ||||||||
Address2: |   | ||||||||
City: | FARRELL | ||||||||
State: | PA | ||||||||
PostalCode: | 161212505 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7249819815 | ||||||||
FaxNumber: | 7249812293 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/13/2005 | ||||||||
LastUpdateDate: | 02/15/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SANDERSON | ||||||||
AuthorizedOfficialFirstName: | KIM | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PESIDENT, CTC DIVISION | ||||||||
AuthorizedOfficialTelephone: | 8552592288 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ACADIA HEALTHCARE COMPANY, INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/15/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X |   |   | N |   | Agencies | Case Management |   | 261Q00000X | 437024 | PA | N |   | Ambulatory Health Care Facilities | Clinic/Center |   | 261QR0405X | 437024 | PA | N |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261QM2800X | 437024 | PA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
ID Information
ID | Type | State | Issuer | Description | 1007554580001 | 05 | PA |   | MEDICAID | 1007554580001 | 01 | PA | COMMUNITY CARE | OTHER | 328401A765137 | 01 | PA | VALUE BEHAVIORAL HEALTH | OTHER |