Healthcare Provider Details

I. General information

NPI: 1356454045
Provider Name (Legal Business Name): EQUILIBRIA PSYCHOLOGICAL AND CONSULTATION SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 06/04/2020
Certification Date: 06/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 S 4TH ST SUITE 471
PHILADELPHIA PA
19147-1570
US

IV. Provider business mailing address

525 S 4TH ST SUITE 471
PHILADELPHIA PA
19147-1570
US

V. Phone/Fax

Practice location:
  • Phone: 267-861-3685
  • Fax: 215-965-1513
Mailing address:
  • Phone: 267-861-3685
  • Fax: 215-965-1513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPS015446
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS015446
License Number StatePA

VIII. Authorized Official

Name: DR. NICOLE ALEXANDRA LIPKIN
Title or Position: OWNER AND EXECUTIVE DIRECTOR
Credential: PSY.D., M.B.A.
Phone: 267-861-3685