Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 251S00000X | Community/Behavioral Health | | | | No |
| 2 | 251S00000X | Community/Behavioral Health | | 104560 | PENNSYLVANIA | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | 1000004060112 | MEDICAID | PALAU | |
| 2 | 600001921 | OTHER | PENNSYLVANIA | MAGELLAN 19133 3849 |
| 3 | 600001922 | OTHER | PENNSYLVANIA | MAGELLAN 19149 1229 |
| 4 | 600001925 | OTHER | PENNSYLVANIA | MAGELLAN 19121 2217 |
| 5 | 600001928 | OTHER | PENNSYLVANIA | MAGELLAN 19144 2153 |
| 6 | 1000004060107 | MEDICAID | PENNSYLVANIA | |
| 7 | 1000004060109 | MEDICAID | PENNSYLVANIA | |
| 8 | 1000004060111 | MEDICAID | PENNSYLVANIA | |
| 9 | 1000004060110 | MEDICAID | PENNSYLVANIA | |
| 10 | 600001917 | OTHER | PENNSYLVANIA | MAGELLAN 19134 3832 |
| 11 | 1000004060136 | MEDICAID | PENNSYLVANIA | |
| 12 | 1000004060137 | MEDICAID | PENNSYLVANIA | |
| 13 | 600001919 | OTHER | PENNSYLVANIA | MAGELLAN 19107 1913 |
| 14 | 1000004060108 | MEDICAID | PENNSYLVANIA | |
| 15 | 1000004060138 | MEDICAID | PENNSYLVANIA | |
| 16 | 600001923 | OTHER | PENNSYLVANIA | MAGELLAN 19104 1361 |