=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528811098
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRANDON PACE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2024
-----------------------------------------------------
Last Update Date | 04/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 202 PARK BLVD APT 237
-----------------------------------------------------
City | CHERRY HILL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08002-3439
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-356-2410
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 202 PARK BLVD APT 237
-----------------------------------------------------
City | CHERRY HILL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08002-3439
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-356-2410
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | CW022592
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------