Provider Demographics
NPI:1073670998
Name:OUTERBRIDGE, ALEXIS
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:OUTERBRIDGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 WALNUT ST STE 1700
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4717
Mailing Address - Country:US
Mailing Address - Phone:215-982-0472
Mailing Address - Fax:215-545-8496
Practice Address - Street 1:1315 WALNUT ST STE 1700
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4717
Practice Address - Country:US
Practice Address - Phone:215-982-0472
Practice Address - Fax:215-545-8496
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0134751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA7919288OtherAETNA PIN
PA7919288OtherAETNA PIN
PA057960Medicare ID - Type Unspecified