MEDICARE: DR. AGNIESZKA A KLECZEK 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	103G00000X	Clinical Neuropsychologist	PSY016016	PA

General Provider Information

NPI Number	:	1558380766
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AGNIESZKA A KLECZEK PH.D

Provider Business Mailing Address
First Line	:	4621 SALMON ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19137-2123
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4621 SALMON ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19137-2123
Country	:	US
Telephone Number	:	267-809-1644
Fax Number	:

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

Provider Enumeration Date	:	07/19/2006
Last Update Date	:	03/23/2009

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