Provider Demographics
NPI:1720703549
Name:MABRY, HASAN TYSHEEM
Entity Type:Individual
Prefix:
First Name:HASAN
Middle Name:TYSHEEM
Last Name:MABRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7949 RIDGE AVE APT F14
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-7004
Mailing Address - Country:US
Mailing Address - Phone:215-868-7197
Mailing Address - Fax:
Practice Address - Street 1:7949 RIDGE AVE APT F14
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-7004
Practice Address - Country:US
Practice Address - Phone:215-868-7197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging