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 | 261QM2800X | Clinic/Center | Methadone | 910194 | PENNSYLVANIA | No |
| 2 | 261QR0405X | Clinic/Center | Rehabilitation, Substance Use Disorder | 910194 | PENNSYLVANIA | No |
| 3 | 251S00000X | Community/Behavioral Health | | 910194 | 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 | 100773886 | MEDICAID | PENNSYLVANIA | |
| 2 | 119272 | OTHER | | COMMUNTIY BEHAVIORAL HEAL |
| 3 | 296503000 | OTHER | PENNSYLVANIA | MAGELLAN HEALTH CHOICES |
| 4 | 046410000 | OTHER | PENNSYLVANIA | MAGELLAN COMMERCIAL |
| 5 | 1000022246 | OTHER | DELAWARE | DIAMOND STATE PARTNERS |
| 6 | 273261 | OTHER | PENNSYLVANIA | MANAGED HEALTH NETWORK |
| 7 | 217465 | OTHER | DELAWARE | UNISON HEALTH PLAN |
| 8 | 311749 | OTHER | PENNSYLVANIA | MAGELLAN - KEYSTONE HPE |
| 9 | 046410000 | OTHER | DELAWARE | MAGELLAN COMMERCIAL |
| 10 | 462315000 | OTHER | PENNSYLVANIA | MAGELLAN HEALTH CHOICES |
| 11 | 119254 | OTHER | PENNSYLVANIA | COMMUNITY BEHAVIORAL HEAL |
| 12 | 0004972000 | OTHER | PENNSYLVANIA | MAGELLAN PERSONAL CHOICE |
| 13 | 100022246 | MEDICAID | DELAWARE | |
| 14 | 159997 | OTHER | DELAWARE | BLUE CROSS DELAWARE |
| 15 | 273261 | OTHER | DELAWARE | MANAGED HEALTH NETWORK |
