MEDICARE: DR. SALLY A. PEARNE 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	PS001701L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0062993000	OTHER	PA	PERSONAL CHOICE

General Provider Information

NPI Number	:	1295837060
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SALLY A. PEARNE PH.D.

Provider Business Mailing Address
First Line	:	11 BALA AVE
Second Line	:	BALA EXECUTIVE COMMONS #48
City	:	BALA CYNWYD
State	:	PA
Zip	:	19004-3201
Country	:	US
Telephone Number	:	215-842-3992
Fax Number	:

Provider Business Practice Location Address
First Line	:	11 BALA AVE
Second Line	:	BALA EXECUTIVE COMMONS #48
City	:	BALA CYNWYD
State	:	PA
Zip	:	19004-3201
Country	:	US
Telephone Number	:	215-842-3992
Fax Number	:

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

Provider Enumeration Date	:	09/02/2006
Last Update Date	:	07/08/2007

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