=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598801656
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THERAPUETIC CENTER AT FOX CHASE AKA THE BRIDGE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2007
-----------------------------------------------------
Last Update Date | 06/25/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8400 PINE ROAD
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-342-5000
-----------------------------------------------------
Fax | 215-342-7709
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8400 PINE ROAD
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-342-5000
-----------------------------------------------------
Fax | 215-342-7709
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. RICHARD J COHEN
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 215-985-2501
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 910093
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------