Healthcare Provider Details

I. General information

NPI: 1720628415
Provider Name (Legal Business Name): BEATA MARIOLA BUZEK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2020
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2514 N BROAD ST
PHILADELPHIA PA
19132-4013
US

IV. Provider business mailing address

617 W CLIVEDEN ST
PHILADELPHIA PA
19119-3651
US

V. Phone/Fax

Practice location:
  • Phone: 215-226-7100
  • Fax:
Mailing address:
  • Phone: 267-602-3404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: