Healthcare Provider Details

I. General information

NPI: 1780043844
Provider Name (Legal Business Name): EFFECTIVE INTERPERSONAL COUNSELING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2016
Last Update Date: 02/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1522B GREGG ST
PHILADELPHIA PA
19115-4283
US

IV. Provider business mailing address

1522B GREGG ST
PHILADELPHIA PA
19115-4283
US

V. Phone/Fax

Practice location:
  • Phone: 215-698-1978
  • Fax:
Mailing address:
  • Phone: 215-698-1978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number6339902
License Number StatePA

VIII. Authorized Official

Name: MR. JONATHAN MICHAEL CLARK
Title or Position: OWNER
Credential: LPC, NCC
Phone: 215-698-1978