Provider Demographics
NPI:1730759341
Name:OPTIMAL AGING
Entity type:Organization
Organization Name:OPTIMAL AGING
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:A
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:215-356-9321
Mailing Address - Street 1:1015 W ALLENS LN
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-3316
Mailing Address - Country:US
Mailing Address - Phone:215-356-9321
Mailing Address - Fax:
Practice Address - Street 1:1015 W ALLENS LN
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19119-3316
Practice Address - Country:US
Practice Address - Phone:215-356-9321
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-26
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health