=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659569135
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTERFACE PSYCH SERVICES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2007
-----------------------------------------------------
Last Update Date | 04/02/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 349 MEETINGHOUSE RD
-----------------------------------------------------
City | JENKINTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19046-2908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-886-5331
-----------------------------------------------------
Fax | 215-576-5949
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 349 MEETINGHOUSE RD
-----------------------------------------------------
City | JENKINTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19046-2908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-886-5331
-----------------------------------------------------
Fax | 215-576-5949
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. ZAKIA WEST
-----------------------------------------------------
Credential | M.B.A.
-----------------------------------------------------
Telephone | 215-886-5331
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------