Basic Information
| Provider Information | |||||||||
| NPI: | 1043304199 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHEAST COMMUNITY MENTAL HEALTH CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2030 W TILGHMAN ST | ||||||||
| Address2: | SUITE 105B | ||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181044354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4842219136 | ||||||||
| FaxNumber: | 4842219130 | ||||||||
| Practice Location | |||||||||
| Address1: | 2927 N 5TH ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191332800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152914357 | ||||||||
| FaxNumber: | 4842219136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 11/09/2007 | ||||||||
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| AuthorizedOfficialLastName: | CHLEBOWSKI | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4842219136 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 105610 | PA | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 1007295290004 | 01 | PA | COMMUNITY BEHAVIORAL HEAL | OTHER | 1007295290004 | 05 | PA | MEDICAID |