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NPI Code Detail

MEDICARE: PATRICIA S CORREA-ILLIDGE LSW

MEDICARE: PATRICIA S CORREA-ILLIDGE LSW
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
1101YM0800XMental Health CounselorSW008617LPA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1001663401OTHERPAINDEPENDENCE BLUE CROSS
2455792000OTHERPAMAGELLAN MIS #

General Provider Information

NPI Number : 1598715179
Entity Type Code : Individual
Provider Name (Legal Business Name) : PATRICIA S CORREA-ILLIDGE LSW
Provider Business Mailing Address
First Line : 432 N 6TH ST
Second Line :
City : PHILADELPHIA
State : PA
Zip : 19123-4004
Country : US
Telephone Number : 215-925-2400
Fax Number : 215-925-9162
Provider Business Practice Location Address
First Line : 4510 FRANKFORD AVE
Second Line : 2ND FLOOR
City : PHILADELPHIA
State : PA
Zip : 19124-3602
Country : US
Telephone Number : 215-831-9882
Fax Number : 215-831-9887
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/12/2006
Last Update Date : 11/01/2015

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Directions to “ PATRICIA S CORREA-ILLIDGE LSW” Practice Location

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