MEDICARE: BALLY RADATTI LPC

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	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1861125593
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BALLY RADATTI LPC

Provider Business Mailing Address
First Line	:	138 BAINBRIDGE ST APT 2
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19147-2402
Country	:	US
Telephone Number	:	215-859-8500
Fax Number	:

Provider Business Practice Location Address
First Line	:	1819 JOHN F KENNEDY BLVD STE 302
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19103-1729
Country	:	US
Telephone Number	:	610-265-3400
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/09/2022
Last Update Date	:	07/09/2022

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