Provider Demographics
NPI:1720668122
Name:PSYREV8808 TRANSFORMATIONAL CENTER
Entity type:Organization
Organization Name:PSYREV8808 TRANSFORMATIONAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MBETTE
Authorized Official - Suffix:
Authorized Official - Credentials:MPSY, LPC
Authorized Official - Phone:215-839-4921
Mailing Address - Street 1:6724 RISING SUN AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19111-4629
Mailing Address - Country:US
Mailing Address - Phone:267-255-0386
Mailing Address - Fax:215-214-5941
Practice Address - Street 1:6724 RISING SUN AVE FL 1
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-4629
Practice Address - Country:US
Practice Address - Phone:267-255-0386
Practice Address - Fax:215-214-5941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-09
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty