Healthcare Provider Details

I. General information

NPI: 1134599608
Provider Name (Legal Business Name): PHILLY FAMILY LIFE COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2015
Last Update Date: 12/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209 GRANT AVE SUITE 2F
PHILADELPHIA PA
19115-3706
US

IV. Provider business mailing address

1209 GRANT AVE SUITE 2F
PHILADELPHIA PA
19115-3706
US

V. Phone/Fax

Practice location:
  • Phone: 215-677-3710
  • Fax: 215-673-2701
Mailing address:
  • Phone: 215-677-3710
  • Fax: 215-673-2701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. EUGENE DEVERS
Title or Position: MANAGING MEMBER OF LLC
Credential: LCSW
Phone: 215-554-8191