Basic Information
| Provider Information | |||||||||
| NPI: | 1750747416 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WORDSWORTH | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 HENRY AVE | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191291121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156435400 | ||||||||
| FaxNumber: | 2675291942 | ||||||||
| Practice Location | |||||||||
| Address1: | 3300 HENRY AVE | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191291121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2456435400 | ||||||||
| FaxNumber: | 2675291942 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2016 | ||||||||
| LastUpdateDate: | 01/12/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LACKS | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 2156435400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 100728361 | PA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 1932242864 | 01 | PA | COMMUNITY BEHAVIORAL HEALTH | OTHER | 1801203567 | 01 | PA | COMMUNITY BEHAVIORAL HEALTH | OTHER | 1114060043 | 01 | PA | COMMUNITY BEHAVIORAL HEALTH | OTHER | 1407806433 | 01 | PA | COMMUNITY BEHAVIORAL HEALTH | OTHER | 1669514774 | 01 | PA | COMMUNITY BEHAVIORAL HEALTH | OTHER | 1477695542 | 01 | PA | COMMUNITY BEHAVIORAL HEALTH | OTHER | 1942342878 | 01 | PA | COMMUNITY BEHAVIORAL HEALTH | OTHER | 1588008643 | 01 | PA | COMMUNITY BEHAVIORAL HEALTH | OTHER | 1841333770 | 01 | PA | COMMUNITY BEHAVIORAL HEALTH | OTHER | 1295877314 | 01 | PA | COMMUNITY BEHAVIORAL HEALTH | OTHER |