Provider Demographics
NPI:1801288667
Name:ESTADT PSYCHOLOGICAL SERVICES, LLC
Entity type:Organization
Organization Name:ESTADT PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:ESTADT
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:267-304-3414
Mailing Address - Street 1:2926 S 15TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-4917
Mailing Address - Country:US
Mailing Address - Phone:267-304-3414
Mailing Address - Fax:
Practice Address - Street 1:1930 S BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-2328
Practice Address - Country:US
Practice Address - Phone:267-304-3414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-03
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA221694Medicare PIN