MEDICARE: LADIPO GROUP PSYCHOTHERAPY FOR OUR COMMUNITY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	CW015409	PA

General Provider Information

NPI Number	:	1063829232
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LADIPO GROUP PSYCHOTHERAPY FOR OUR COMMUNITY LLC

Provider Business Mailing Address
First Line	:	255 S 17TH ST STE 2704
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19103-6228
Country	:	US
Telephone Number	:	267-908-6363
Fax Number	:

Provider Business Practice Location Address
First Line	:	255 S 17TH ST STE 2704
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19103-6228
Country	:	US
Telephone Number	:	267-908-6363
Fax Number	:

Authorized Official
Title or Position	:	OWNER & DIRECTOR
Name	:	TONYA LADIPO
Credential	:
Telephone Number	:	267-908-6363

Provider Enumeration Date	:	07/18/2014
Last Update Date	:	03/29/2021

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