=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861916470
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SONG AND REITZ PSYCHOLOGICAL ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20 CEDAR BLVD STE 305
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15228-1330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-660-3598
-----------------------------------------------------
Fax | 412-668-0903
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20 CEDAR BLVD STE 305
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15228-1330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-660-3598
-----------------------------------------------------
Fax | 412-668-0903
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO OWNER
-----------------------------------------------------
Name | TIFFANY TIPTON SONG
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 412-660-3598
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | CW015469
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | PS017481
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------