=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396497640
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHILADELPHIA CENTER FOR PSYCHOTHERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2022
-----------------------------------------------------
Last Update Date | 01/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 255 S 17TH ST STE 1601
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19103-6216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-277-3179
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 255 S 17TH ST STE 1601
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19103-6216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL PSYCHOLOGIST, OWNER
-----------------------------------------------------
Name | DR. HIDER SHAABAN
-----------------------------------------------------
Credential | PSYD
-----------------------------------------------------
Telephone | 267-277-3179
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------