Healthcare Provider Details

I. General information

NPI: 1407279581
Provider Name (Legal Business Name): HEALTH PROMOTION COUNCIL OF SOUTHEASTERN PENNSYLVANIA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2014
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 MARKET ST CENTRE SQUARE EAST
PHILADELPHIA PA
19102-2100
US

IV. Provider business mailing address

1500 MARKET ST CENTRE SQUARE EAST
PHILADELPHIA PA
19102-2100
US

V. Phone/Fax

Practice location:
  • Phone: 215-731-6150
  • Fax: 215-731-6199
Mailing address:
  • Phone: 215-731-6150
  • Fax: 215-731-6199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: PAMELA EVERETT CLARKE
Title or Position: SR DIRECTOR QUALITY OPERATIONS
Credential:
Phone: 267-765-2334