Healthcare Provider Details

I. General information

NPI: 1477977346
Provider Name (Legal Business Name): RANDY MORMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2014
Last Update Date: 02/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2514 N. BROAD STREET 1ST FLOOR
PHILADELPHIA PA
19132
US

IV. Provider business mailing address

804 N. UBER ST
PHILADELPHIA PA
19130
US

V. Phone/Fax

Practice location:
  • Phone: 215-599-2845
  • Fax: 215-599-1043
Mailing address:
  • Phone: 215-599-2845
  • Fax: 215-599-1043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: