=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952841041
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PERSONAL CARE HOME C&G
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2017
-----------------------------------------------------
Last Update Date | 03/08/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6176 NEWTOWN AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-235-7138
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6176 NEWTOWN AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19111-5928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-235-7138
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MENTAL HEALTH COUNSELOR
-----------------------------------------------------
Name | DANIELLE DAVIS
-----------------------------------------------------
Credential | M. A
-----------------------------------------------------
Telephone | 267-235-7138
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305S00000X
-----------------------------------------------------
Taxonomy Name | Point of Service
-----------------------------------------------------
License Number | 724086
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------