MEDICARE: CAROLYN TRUESDALE PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	PS015386	PA

General Provider Information

NPI Number	:	1063492635
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROLYN TRUESDALE PH.D.

Provider Business Mailing Address
First Line	:	4700 WISSAHICKON AVE
Second Line	:	SUITE 118 BOX 110
City	:	PHILADELPHIA
State	:	PA
Zip	:	19144-4248
Country	:	US
Telephone Number	:	215-298-0417
Fax Number	:	215-298-0502

Provider Business Practice Location Address
First Line	:	3205 DEFENSE TER
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19129-1110
Country	:	US
Telephone Number	:	215-843-9729
Fax Number	:	215-843-7313

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/19/2006
Last Update Date	:	07/08/2007

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