Provider Demographics
NPI:1902232242
Name:TICE, CORRIE ANN
Entity Type:Individual
Prefix:
First Name:CORRIE
Middle Name:ANN
Last Name:TICE
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 1:260 S. BROAD STREET
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-5126
Mailing Address - Country:US
Mailing Address - Phone:215-985-2500
Mailing Address - Fax:267-765-2325
Practice Address - Street 1:125 S 9TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5125
Practice Address - Country:US
Practice Address - Phone:215-592-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-18
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW1306841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical