Provider Demographics
NPI:1669504213
Name:PRIMAVERA, JOSEPH P III (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:P
Last Name:PRIMAVERA
Suffix:III
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 CHESTNUT ST
Mailing Address - Street 2:SUITE 430
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4316
Mailing Address - Country:US
Mailing Address - Phone:215-625-9770
Mailing Address - Fax:215-625-9866
Practice Address - Street 1:1015 CHESTNUT ST
Practice Address - Street 2:SUITE 430
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4316
Practice Address - Country:US
Practice Address - Phone:215-625-9770
Practice Address - Fax:215-625-9866
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PWPS 0047-16L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0063157000OtherMAGELLAN HEALTH SERVICES
PA4404301OtherAETNA
PA250823000OtherMAGELLAN PROVIDER MIS
PAR07157Medicare UPIN
PA485672Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID