Provider Demographics
NPI:1912092545
Name:BREWER, RICHARD J (MFT)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
Last Name:BREWER
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1315 WALNUT ST
Mailing Address - Street 2:#1003
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4719
Mailing Address - Country:US
Mailing Address - Phone:215-764-5728
Mailing Address - Fax:215-875-9975
Practice Address - Street 1:1315 WALNUT ST
Practice Address - Street 2:#1003
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4719
Practice Address - Country:US
Practice Address - Phone:215-764-5728
Practice Address - Fax:215-875-9975
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC35609106H00000X
PAMF000617106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist