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General NPI Number Information
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NPI Number | 1548042450
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Entity Type | Organization
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Legal Business Name | REDEFINE LIVES, LLC
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Dates
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Enumeration Date | 10/16/2023
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Last Update Date | 10/16/2023
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Provider Practice Location Address
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Address Line | 7113 MONTAGUE STREET
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City | PHILADELPHIA
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State | PA
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Zip | 19135
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Country | US
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Telephone | 267-752-9421
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Fax | 888-892-2862
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Provider Business Mailing Address
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Address Line | 1500 CHESTNUT ST STE 2
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City | PHILADELPHIA
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State | PA
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Zip | 19102-2700
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Country | US
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Telephone | 267-752-9421
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Fax | 888-892-2862
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Authorized Official
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Title or Position | OWNER
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Name | TYSHEIRA MADDOX
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Credential | LCSW
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Telephone | 267-752-9421
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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