Provider Demographics
NPI:1891287009
Name:FISEHA, REDET
Entity Type:Individual
Prefix:
First Name:REDET
Middle Name:
Last Name:FISEHA
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 1:551 W LANCASTER AVE
Mailing Address - Street 2:
Mailing Address - City:HAVERFORD
Mailing Address - State:PA
Mailing Address - Zip Code:19041-1419
Mailing Address - Country:US
Mailing Address - Phone:267-475-7808
Mailing Address - Fax:
Practice Address - Street 1:1801 S 22ND ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-1940
Practice Address - Country:US
Practice Address - Phone:267-475-7808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-04
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
123456789OtherNO LICENSE