Provider Demographics
NPI:1336657709
Name:ADDIS, EILEEN B (LCSW)
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:B
Last Name:ADDIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 MALLARD RD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19087-2344
Mailing Address - Country:US
Mailing Address - Phone:610-247-8504
Mailing Address - Fax:
Practice Address - Street 1:4100 MAIN ST STE 403
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19127-1623
Practice Address - Country:US
Practice Address - Phone:215-487-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-18
Last Update Date:2024-07-05
Deactivation Date:2021-06-28
Deactivation Code:
Reactivation Date:2024-07-05
Provider Licenses
StateLicense IDTaxonomies
PACW0183871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical