1912015603 NPI number — ANXIETY & AGORAPHOBIA TREATMENT CENTER, PC

Table of content: (NPI 1912015603)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912015603 NPI number — ANXIETY & AGORAPHOBIA TREATMENT CENTER, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANXIETY & AGORAPHOBIA TREATMENT CENTER, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
AGORAPHOBIA & ANXIETY TREATMENT CENTER
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912015603
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
112 BALA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALA CYNWYD
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19004-3025
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-667-6490
Provider Business Mailing Address Fax Number:
610-667-1744

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
112 BALA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALA CYNWYD
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19004-3025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-667-6490
Provider Business Practice Location Address Fax Number:
610-667-1744
Provider Enumeration Date:
08/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FOSTER-DALEY
Authorized Official First Name:
BARBARA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
610-667-6490

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 027365000 . This is a "MAGELLAN BEHAVIORAL HEALT" identifier . This identifiers is of the category "OTHER".




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