Basic Information
| Provider Information | |||||||||
| NPI: | 1952485864 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DELAWARE COUNTY PROFESSIONAL SERVICES, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | LIFESTANCE HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1055 E BALTIMORE PIKE STE 303 | ||||||||
| Address2: | |||||||||
| City: | MEDIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190635173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108923800 | ||||||||
| FaxNumber: | 4844681412 | ||||||||
| Practice Location | |||||||||
| Address1: | 1055 E BALTIMORE PIKE STE 303 | ||||||||
| Address2: | |||||||||
| City: | MEDIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190635173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6108923800 | ||||||||
| FaxNumber: | 4844681412 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 09/09/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PARDO | ||||||||
| AuthorizedOfficialFirstName: | RYAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 2063991493 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.