Provider Demographics
NPI:1922162130
Name:PHILADELPHIA SCHOOL OF PSYCHOANALYSIS
Entity Type:Organization
Organization Name:PHILADELPHIA SCHOOL OF PSYCHOANALYSIS
Other - Org Name:PHILADELPHIA CONSULATION CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:CORREALE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, NCPSYA
Authorized Official - Phone:215-732-8244
Mailing Address - Street 1:313 S 16TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-4908
Mailing Address - Country:US
Mailing Address - Phone:215-732-8244
Mailing Address - Fax:215-732-8454
Practice Address - Street 1:313 S 16TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-4908
Practice Address - Country:US
Practice Address - Phone:215-732-8244
Practice Address - Fax:215-732-8454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X, 103TC0700X, 103TC1900X, 103TC2200X, 103TH0004X, 104100000X, 1041C0700X
PA122030261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealthGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007645820002Medicaid
PA1007645820002Medicaid