Provider Demographics
NPI:1649377003
Name:COMMUNITY COUNCIL FOR MH/MR, INC.
Entity type:Organization
Organization Name:COMMUNITY COUNCIL FOR MH/MR, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:EARLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-473-7033
Mailing Address - Street 1:4900 WYALUSING AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-5127
Mailing Address - Country:US
Mailing Address - Phone:215-473-7033
Mailing Address - Fax:215-473-5405
Practice Address - Street 1:4900 WYALUSING AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-5127
Practice Address - Country:US
Practice Address - Phone:215-473-7033
Practice Address - Fax:215-473-5405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA121630261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA00096047Medicare ID - Type Unspecified