Basic Information
| Provider Information | |||||||||
| NPI: | 1740954700 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IRELAND | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | PMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3005 GRAYS FERRY AVE UNIT 3809 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191465300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156092701 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3535 MARKET ST STE 1230 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191043309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108923800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2021 | ||||||||
| LastUpdateDate: | 08/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | SP024157 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.