Provider Demographics
NPI:1265031603
Name:CENTER FOR INTEGRATIVE PSYCHIATRY AND NEUROMODULATION, PLLC
Entity Type:Organization
Organization Name:CENTER FOR INTEGRATIVE PSYCHIATRY AND NEUROMODULATION, PLLC
Other - Org Name:AXON PSYCHIATRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:RHODE
Authorized Official - Last Name:STODDARD
Authorized Official - Suffix:II
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:215-292-4007
Mailing Address - Street 1:822 MONTGOMERY AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:NARBERTH
Mailing Address - State:PA
Mailing Address - Zip Code:19072-1946
Mailing Address - Country:US
Mailing Address - Phone:215-565-1005
Mailing Address - Fax:215-494-1070
Practice Address - Street 1:822 MONTGOMERY AVE STE 207
Practice Address - Street 2:
Practice Address - City:NARBERTH
Practice Address - State:PA
Practice Address - Zip Code:19072-1946
Practice Address - Country:US
Practice Address - Phone:215-565-1005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PSYCHIATRIC ASSOCIATES OF PENNSYLVANIA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-10-17
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty