MEDICARE: CLINICALRESOURCEGROUP,INC.

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	101YM0800X	Mental Health Counselor	CWO12105	PA

General Provider Information

NPI Number	:	1841490877
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLINICALRESOURCEGROUP,INC.

Provider Business Mailing Address
First Line	:	8703 WEST CHESTER PIKE
Second Line	:	2ND FLOOR
City	:	UPPER DARBY
State	:	PA
Zip	:	19082
Country	:	US
Telephone Number	:	610-853-9431
Fax Number	:	610-853-9431

Provider Business Practice Location Address
First Line	:	8703 W CHESTER PIKE
Second Line	:	2ND FLOOR
City	:	UPPER DARBY
State	:	PA
Zip	:	19082-1115
Country	:	US
Telephone Number	:	610-853-9431
Fax Number	:	610-853-9431

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. ROCHELLE POLAO
Credential	:	LCSW
Telephone Number	:	610-853-9431

Provider Enumeration Date	:	07/18/2007
Last Update Date	:	07/18/2007

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