Provider Demographics
NPI:1740954700
Name:IRELAND, MICHAEL (PMHNP)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:IRELAND
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3005 GRAYS FERRY AVE UNIT 3809
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-5300
Mailing Address - Country:US
Mailing Address - Phone:215-609-2701
Mailing Address - Fax:
Practice Address - Street 1:3535 MARKET ST STE 1230
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-3309
Practice Address - Country:US
Practice Address - Phone:610-892-3800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-04
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP024157363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health