Healthcare Provider Details

I. General information

NPI: 1083100879
Provider Name (Legal Business Name): SUMMIT GROVE THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2018
Last Update Date: 07/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 SUMMIT GROVE AVE STE 211
BRYN MAWR PA
19010-3230
US

IV. Provider business mailing address

26 SUMMIT GROVE AVE STE 211
BRYN MAWR PA
19010-3230
US

V. Phone/Fax

Practice location:
  • Phone: 484-442-0478
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC006299
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW012101
License Number StatePA

VIII. Authorized Official

Name: SARA RALPH
Title or Position: OWNER, THERAPIST
Credential:
Phone: 717-222-0361