Basic Information
| Provider Information | |||||||||
| NPI: | 1205290970 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TCM ADOLESCENT INITIATIVE AND FAMILY CARE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3401 CIVIC CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191044319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155902897 | ||||||||
| FaxNumber: | 2674266313 | ||||||||
| Practice Location | |||||||||
| Address1: | 3550 MARKET ST | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191043329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155902956 | ||||||||
| FaxNumber: | 2155907121 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2016 | ||||||||
| LastUpdateDate: | 07/12/2022 | ||||||||
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| AuthorizedOfficialLastName: | BLEACHER | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 2674266179 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHILDERN'S HOSPTIAL OF PHILADELPHIA | ||||||||
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| NPICertificationDate: | 07/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.