Healthcare Provider Details

I. General information

NPI: 1720288913
Provider Name (Legal Business Name): TRANSITION PHASE III
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2007
Last Update Date: 04/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 CITY AVE MADISON BLDG SUITE 1207
PHILADELPHIA PA
19131-2908
US

IV. Provider business mailing address

3900 CITY AVENUE MADISON BLDG SUITE 1207
PHILADELPHIA PA
19131-0000
US

V. Phone/Fax

Practice location:
  • Phone: 215-878-3052
  • Fax: 215-878-3532
Mailing address:
  • Phone: 215-878-3052
  • Fax: 215-878-3532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MS. JO BENAIT
Title or Position: CEO GROUP ADMINISTRATOR
Credential: PSYD
Phone: 215-878-3052