Main Line Mental Health LLC

Primary specialty

Psychiatry PhysicianTaxonomy code 2084P0800X

License

MD04514OL Issued in PA

Legal business name

MAIN LINE MENTAL HEALTH LLC

Practice address

349 Lancaster Ave
Suite 103
Haverford, PA 19041-1500

Phone

(610) 945-5259

Fax

(610) 664-7061

NPI assigned

Jun 3, 2011

Last updated

Jun 3, 2011By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Jonathan Gershon Shack, MD

Title

Single Member LLC

Phone

(610) 945-5259

Specialties & licenses 1

Addresses

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1307059200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1307059200000",
    "number": "1083908388",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "349 WEST LANCASTER AVENUE",
            "address_2": "SUITE 103",
            "city": "HAVERFORD",
            "state": "PA",
            "postal_code": "190411500",
            "telephone_number": "610-945-5259",
            "fax_number": "610-664-7061"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "349 LANCASTER AVE",
            "address_2": "SUITE 103",
            "city": "HAVERFORD",
            "state": "PA",
            "postal_code": "190411500",
            "telephone_number": "610-945-5259",
            "fax_number": "610-664-7061"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MAIN LINE MENTAL HEALTH LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-06-03",
        "last_updated": "2011-06-03",
        "status": "A",
        "authorized_official_last_name": "SHACK",
        "authorized_official_first_name": "JONATHAN",
        "authorized_official_middle_name": "GERSHON",
        "authorized_official_title_or_position": "SINGLE MEMBER LLC",
        "authorized_official_telephone_number": "610-945-5259",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "2084P0800X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "PA",
            "license": "MD04514OL",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Rebecca Livingston, MA, LPC
• Kathleen Long, MD
• Donald C Lonnquist, MA, ATR-BC, LPC
• Susan Magargee, MD
• Wendy A. Mahoney, RN, CRNP
• Main Line Retina
• Main Line Speech Consultants, LTD.
• Main Line Therapy Solutions
• Main Line Therapy Solutions, LLC
• Katie Anne Manganello, PSYD

• Psychiatry Physician in Haverford, PA
• Providers in Haverford, PA by specialty
• Psychiatry Physician in Pennsylvania

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 3, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.