MEDICARE: DR. CHRISTINE M NEZU 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	103TC0700X	Clinical Psychologist	PS-006015-L	PA

General Provider Information

NPI Number	:	1205876398
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHRISTINE M NEZU PH.D.

Provider Business Mailing Address
First Line	:	1505 RACE ST
Second Line	:	ROOM 306 A PSYCHOLOGY
City	:	PHILADELPHIA
State	:	PA
Zip	:	19102-1119
Country	:	US
Telephone Number	:	215-762-3677
Fax Number	:	215-762-8683

Provider Business Practice Location Address
First Line	:	1505 RACE ST
Second Line	:	ROOM 306 A PSYCHOLOGY
City	:	PHILADELPHIA
State	:	PA
Zip	:	19102-1119
Country	:	US
Telephone Number	:	215-762-3677
Fax Number	:	215-762-8683

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

Provider Enumeration Date	:	06/07/2006
Last Update Date	:	07/08/2007

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