Provider Demographics
NPI:1144830738
Name:AVIVA MENTAL HEALTH SERVICES INC
Entity type:Organization
Organization Name:AVIVA MENTAL HEALTH SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSMARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHARLES
Authorized Official - Suffix:
Authorized Official - Credentials:MHS
Authorized Official - Phone:610-522-4506
Mailing Address - Street 1:320 MACDADE BLVD STE 205
Mailing Address - Street 2:
Mailing Address - City:DARBY
Mailing Address - State:PA
Mailing Address - Zip Code:19023-1926
Mailing Address - Country:US
Mailing Address - Phone:610-522-4506
Mailing Address - Fax:610-522-4508
Practice Address - Street 1:219 W 9TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19801-1619
Practice Address - Country:US
Practice Address - Phone:610-522-4506
Practice Address - Fax:610-522-4508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-07
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1034994870001Medicaid