=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619620507
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FRANCIS IACOBUCCI COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2022
-----------------------------------------------------
Last Update Date | 01/31/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4 RAYMOND DR STE F
-----------------------------------------------------
City | HAVERTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19083-3188
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-437-1163
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 715 20TH AVE E
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98112-4015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-437-1163
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER AND CEO
-----------------------------------------------------
Name | MR. FRANCIS REGINALD IACOBUCCI III
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 484-437-1163
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------