=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699290536
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CREATIVE PLAY & FAMILY COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2017
-----------------------------------------------------
Last Update Date | 08/11/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 233 E LANCASTER AVE STE 104
-----------------------------------------------------
City | ARDMORE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19003-2321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-483-1360
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 624 RENZ ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19128-1419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-802-7557
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOTHERAPIST
-----------------------------------------------------
Name | MRS. IRENE P PSIHOGIOS
-----------------------------------------------------
Credential | LPC, RPT
-----------------------------------------------------
Telephone | 484-802-7557
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 007248
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------