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General NPI Number Information
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NPI Number | 1619367489
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Entity Type | Organization
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Legal Business Name | INDEPENDENT CONTRACTOR
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Dates
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Enumeration Date | 01/30/2015
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Last Update Date | 01/30/2015
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Provider Practice Location Address
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Address Line | 9406 KREWSTOWN RD
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City | PHILADELPHIA
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State | PA
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Zip | 19115-3713
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Country | US
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Telephone | 215-464-2939
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Fax |
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Provider Business Mailing Address
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Address Line | 9406 KREWSTOWN RD
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City | PHILADELPHIA
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State | PA
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Zip | 19115-3713
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Country | US
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Telephone | 215-464-2939
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Fax |
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Authorized Official
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Title or Position | BSC
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Name | MR. NWABUNWANNE ANTHONY OKAFOR
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Credential | MS, MBA
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Telephone | 215-715-7999
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | BH002478
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License Number State | PA
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