Provider Demographics
NPI:1285062778
Name:REYNALDO TOMAS PALACIO
Entity type:Organization
Organization Name:REYNALDO TOMAS PALACIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL/BEHAVIAL-PSYCHOTHERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:REYNALDO
Authorized Official - Middle Name:TOMAS
Authorized Official - Last Name:PALACIO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW,CCBT
Authorized Official - Phone:215-913-0870
Mailing Address - Street 1:3302 TILDEN ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1412
Mailing Address - Country:US
Mailing Address - Phone:215-913-0870
Mailing Address - Fax:215-703-5367
Practice Address - Street 1:3302 TILDEN ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19129-1412
Practice Address - Country:US
Practice Address - Phone:215-913-0870
Practice Address - Fax:215-703-5367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-22
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0143601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA=========-AMedicaid