Healthcare Provider Details

I. General information

NPI: 1235738360
Provider Name (Legal Business Name): HALLIE M. KUSHNER, PH.D. P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2020
Last Update Date: 10/20/2020
Certification Date: 10/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 WALNUT ST STE 706
PHILADELPHIA PA
19102-2904
US

IV. Provider business mailing address

1031 SPRUCE ST APT 203
PHILADELPHIA PA
19107-6726
US

V. Phone/Fax

Practice location:
  • Phone: 215-839-9735
  • Fax:
Mailing address:
  • Phone: 773-308-5636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: HALLIE M KUSHNER
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 215-839-9735