Provider Demographics
NPI:1982766564
Name:PROFESSIONAL CLINICAL FORUM
Entity Type:Organization
Organization Name:PROFESSIONAL CLINICAL FORUM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:MULLIGAN
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:215-956-0334
Mailing Address - Street 1:142 E MORELAND AVE
Mailing Address - Street 2:PCF MANAGING PARTNER
Mailing Address - City:HATBORO
Mailing Address - State:PA
Mailing Address - Zip Code:19040-4714
Mailing Address - Country:US
Mailing Address - Phone:215-956-0334
Mailing Address - Fax:215-956-0308
Practice Address - Street 1:142 E MORELAND AVE
Practice Address - Street 2:PCF MANAGING PARTNER
Practice Address - City:HATBORO
Practice Address - State:PA
Practice Address - Zip Code:19040-4714
Practice Address - Country:US
Practice Address - Phone:215-956-0334
Practice Address - Fax:215-956-0308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS001156L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0162452900001Medicaid