MEDICARE: INSIGHTFUL MEDIATION

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	CW018347	PA

General Provider Information

NPI Number	:	1902297419
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INSIGHTFUL MEDIATION

Provider Business Mailing Address
First Line	:	6213 N HANCOCK ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19120-1504
Country	:	US
Telephone Number	:	215-480-5122
Fax Number	:

Provider Business Practice Location Address
First Line	:	6213 N HANCOCK ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19120-1504
Country	:	US
Telephone Number	:	215-480-5122
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	TIFFANY HARRIS
Credential	:	LCSW
Telephone Number	:	215-480-5122

Provider Enumeration Date	:	02/05/2015
Last Update Date	:	02/05/2015

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Directions to “INSIGHTFUL MEDIATION ” Practice Location

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