Provider Demographics
NPI:1013124189
Name:KAREN KEVRESHE
Entity type:Organization
Organization Name:KAREN KEVRESHE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CLINICAL AFFAIRS
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:ETTINGOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-496-0707
Mailing Address - Street 1:238 S CAMAC ST
Mailing Address - Street 2:3B
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-7019
Mailing Address - Country:US
Mailing Address - Phone:267-234-1833
Mailing Address - Fax:
Practice Address - Street 1:417 N 8TH ST
Practice Address - Street 2:402
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19123-3916
Practice Address - Country:US
Practice Address - Phone:215-496-0707
Practice Address - Fax:215-627-9042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACWO150241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty