Basic Information
| Provider Information | |||||||||
| NPI: | 1194889022 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WOMANSPACE ARDMORE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 WISSAHICKON AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191444248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159510300 | ||||||||
| FaxNumber: | 2159510312 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 ARDMORE AVE | ||||||||
| Address2: | |||||||||
| City: | ARDMORE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190031315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106498136 | ||||||||
| FaxNumber: | 6106494270 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2006 | ||||||||
| LastUpdateDate: | 05/27/2010 | ||||||||
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| AuthorizedOfficialLastName: | MOONEY | ||||||||
| AuthorizedOfficialFirstName: | LORETTA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | AR COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 2159510300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | MS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 1000017080229 | PA | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
ID Information
| ID | Type | State | Issuer | Description | 1000017080229 | 05 | PA | MEDICAID | 153373-000 | 01 | PA | WOMANSPACE ARDMORE MAG | OTHER |