Provider Demographics
NPI:1720722978
Name:LI, XIAOWEI (M PHILED)
Entity type:Individual
Prefix:
First Name:XIAOWEI
Middle Name:
Last Name:LI
Suffix:
Gender:M
Credentials:M PHILED
Other - Prefix:
Other - First Name:DEREK
Other - Middle Name:
Other - Last Name:LI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MPHILED
Mailing Address - Street 1:413 LIBERTY LN
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-5344
Mailing Address - Country:US
Mailing Address - Phone:510-676-6202
Mailing Address - Fax:
Practice Address - Street 1:115 BLOOMINGDALE AVE
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:PA
Practice Address - Zip Code:19087-4030
Practice Address - Country:US
Practice Address - Phone:484-887-8385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-25
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YA0400X, 101YM0800X
PAPC016319101YP2500X
NJ37PC01031200101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health