Healthcare Provider Details

I. General information

NPI: 1902624596
Provider Name (Legal Business Name): YEONG J BAE LCSW, M.DIV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2024
Last Update Date: 09/26/2026
Certification Date: 09/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 COMMERCE DR
FORT WASHINGTON PA
19034-2600
US

IV. Provider business mailing address

2003 BALLANTINE LN
WARRINGTON PA
18976-2738
US

V. Phone/Fax

Practice location:
  • Phone: 267-337-8213
  • Fax: 833-367-0993
Mailing address:
  • Phone: 610-937-5615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW027982
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: