Healthcare Provider Details

I. General information

NPI: 1518714989
Provider Name (Legal Business Name): MARY NARZIKUL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2024
Last Update Date: 05/03/2024
Certification Date: 05/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 CHESTNUT ST STE 1520
PHILADELPHIA PA
19107-4315
US

IV. Provider business mailing address

PO BOX 748465
ATLANTA GA
30374-8465
US

V. Phone/Fax

Practice location:
  • Phone: 855-675-4010
  • Fax:
Mailing address:
  • Phone: 855-284-7483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC016675
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: