Provider Demographics
NPI:1750577920
Name:GAGE, BETH MARIE (CNS)
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:MARIE
Last Name:GAGE
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5501 OLD YORK RD
Mailing Address - Street 2:LEVY 9TH FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19141-0000
Mailing Address - Country:US
Mailing Address - Phone:215-456-7025
Mailing Address - Fax:215-456-7692
Practice Address - Street 1:5501 OLD YORK RD
Practice Address - Street 2:LEVY 9TH FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-0000
Practice Address - Country:US
Practice Address - Phone:215-456-7025
Practice Address - Fax:215-456-7692
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-20
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN-340576-L364SP0809X, 364SP0813X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
No364SP0813XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Geropsychiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
S67864Medicare UPIN