Provider Demographics
NPI:1437490174
Name:MCKITTHEN, PERCY JUNIOR (BA)
Entity Type:Individual
Prefix:MR
First Name:PERCY
Middle Name:JUNIOR
Last Name:MCKITTHEN
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6445 N BROAD ST
Mailing Address - Street 2:APT 1
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19126-3626
Mailing Address - Country:US
Mailing Address - Phone:267-221-8713
Mailing Address - Fax:
Practice Address - Street 1:5353 LINDBERGH BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19143-5829
Practice Address - Country:US
Practice Address - Phone:267-770-2878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-05
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA3269676171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator