Provider Demographics
NPI:1679189641
Name:TEEN SUPPORT CENTER, LLC
Entity Type:Organization
Organization Name:TEEN SUPPORT CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:KEATES MAY
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:610-813-2575
Mailing Address - Street 1:1528 WALNUT ST STE 2012
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-3613
Mailing Address - Country:US
Mailing Address - Phone:610-813-2575
Mailing Address - Fax:
Practice Address - Street 1:1528 WALNUT ST STE 2012
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-3613
Practice Address - Country:US
Practice Address - Phone:610-813-2575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty