Basic Information
| Provider Information | |||||||||
| NPI: | 1588008643 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WORDSWORTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3905 FORD RD | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191312824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156435400 | ||||||||
| FaxNumber: | 2158713412 | ||||||||
| Practice Location | |||||||||
| Address1: | 2101 PENNSYLVANIA AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WASHINGTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190342912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007690088 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2013 | ||||||||
| LastUpdateDate: | 04/19/2013 | ||||||||
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| AuthorizedOfficialLastName: | LACKS | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2156435400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251C00000X | Y | Agencies | Day Training, Developmentally Disabled Services |
ID Information
| ID | Type | State | Issuer | Description | 1407806433 | 05 | PA | MEDICAID |