1235595943 NPI number — DR. MARIA CONNIE PANDOLFI

Table of content: DR. MARIA CONNIE PANDOLFI (NPI 1235595943)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235595943 NPI number — DR. MARIA CONNIE PANDOLFI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PANDOLFI
Provider First Name:
MARIA
Provider Middle Name:
CONNIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LOPEZ
Provider Other First Name:
MARIA
Provider Other Middle Name:
CONNIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1235595943
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1001 CITY AVE UNIT WA804
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WYNNEWOOD
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19096-3939
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-834-3733
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 CITY AVE UNIT WA804
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WYNNEWOOD
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19096-3939
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
646-981-7059
Provider Business Practice Location Address Fax Number:
610-206-3785
Provider Enumeration Date:
01/11/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  SW6295 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: CW018917 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 018344400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: IO401A . This is a "MEDICARE PTAN GRP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: IO402Z . This is a "MEDICARE PTAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".