=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316109549
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DARA BETH ABRAHAM D.O
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/29/2008
-----------------------------------------------------
Last Update Date | 07/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1601 WALNUT ST STE 1128
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19102-2913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-686-9161
-----------------------------------------------------
Fax | 610-273-5562
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1722 SYLVAN LN
-----------------------------------------------------
City | GLADWYNE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19035-1221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-686-9161
-----------------------------------------------------
Fax | 610-273-5562
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | OS015113
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------