Basic Information
| Provider Information | |||||||||
| NPI: | 1578989836 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CITYWIDE COMMUNITY COUNSELING SERVICES, | ||||||||
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| Mailing Information | |||||||||
| Address1: | 537 E ALLEGHENY AVE | ||||||||
| Address2: | APT/SUITE | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191342328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152919500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 537 E ALLEGHENY AVE | ||||||||
| Address2: | APT/SUITE | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191342328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152919500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2014 | ||||||||
| LastUpdateDate: | 03/11/2014 | ||||||||
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| AuthorizedOfficialLastName: | MOLINA | ||||||||
| AuthorizedOfficialFirstName: | MODESTA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF OF OPERATION | ||||||||
| AuthorizedOfficialTelephone: | 2152919500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
No ID Information.