MEDICARE: ALEXIS OUTERBRIDGE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	CW013475	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7919288	OTHER	PA	AETNA PIN

General Provider Information

NPI Number	:	1073670998
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEXIS OUTERBRIDGE

Provider Business Mailing Address
First Line	:	1315 WALNUT ST STE 1700
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19107-4717
Country	:	US
Telephone Number	:	215-982-0472
Fax Number	:	215-545-8496

Provider Business Practice Location Address
First Line	:	1315 WALNUT ST STE 1700
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19107-4717
Country	:	US
Telephone Number	:	215-982-0472
Fax Number	:	215-545-8496

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/02/2007
Last Update Date	:	07/08/2007

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Directions to “ ALEXIS OUTERBRIDGE ” Practice Location

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