=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821600123
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSEPH HERBERT GAINES LPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2020
-----------------------------------------------------
Last Update Date | 08/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2101 S BROAD ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19148-2941
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-400-8400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 40 WAGON LN
-----------------------------------------------------
City | CHERRY HILL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08002-1560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-438-1031
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | PC009381
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------