Healthcare Provider Details

I. General information

NPI: 1821292053
Provider Name (Legal Business Name): KIM MEREDITH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1823 CALLOWHILL ST
PHILADELPHIA PA
19130-4109
US

IV. Provider business mailing address

1823 CALLOWHILL ST
PHILADELPHIA PA
19130-4109
US

V. Phone/Fax

Practice location:
  • Phone: 212-496-0707
  • Fax: 215-496-0742
Mailing address:
  • Phone: 212-496-0707
  • Fax: 215-496-0742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW014399
License Number StatePA

VIII. Authorized Official

Name: DR. ANDREA ETTINGOFF
Title or Position: DIRECTOR OF CLINICAL & QA
Credential:
Phone: 215-496-9797