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General NPI Number Information
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NPI Number | 1720668122
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Entity Type | Organization
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Legal Business Name | PSYREV8808 TRANSFORMATIONAL CENTER
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Dates
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Enumeration Date | 04/09/2021
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Last Update Date | 04/09/2021
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Provider Practice Location Address
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Address Line | 6724 RISING SUN AVE FL 1
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City | PHILADELPHIA
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State | PA
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Zip | 19111-4629
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Country | US
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Telephone | 267-255-0386
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Fax | 215-214-5941
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Provider Business Mailing Address
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Address Line | 6724 RISING SUN AVE FL 1
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City | PHILADELPHIA
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State | PA
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Zip | 19111-4629
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Country | US
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Telephone | 267-255-0386
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Fax | 215-214-5941
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Authorized Official
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Title or Position | PRESIDENT
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Name | ANNE MBETTE
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Credential | MPSY, LPC
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Telephone | 215-839-4921
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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