Healthcare Provider Details

I. General information

NPI: 1205290970
Provider Name (Legal Business Name): TCM ADOLESCENT INITIATIVE AND FAMILY CARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2016
Last Update Date: 07/12/2022
Certification Date: 07/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3550 MARKET ST 5TH FLOOR
PHILADELPHIA PA
19104-3329
US

IV. Provider business mailing address

3401 CIVIC CENTER BLVD
PHILADELPHIA PA
19104-4319
US

V. Phone/Fax

Practice location:
  • Phone: 215-590-2956
  • Fax: 215-590-7121
Mailing address:
  • Phone: 215-590-2897
  • Fax: 267-426-6313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name: EDWARD BLEACHER
Title or Position: VP
Credential:
Phone: 267-426-6179