MEDICARE: DR. DAVID KEELTY PRINCE PSYD

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	PS015449	PA

General Provider Information

NPI Number	:	1578596359
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID KEELTY PRINCE PSYD

Provider Business Mailing Address
First Line	:	1518 WALNUT ST
Second Line	:	SUITE 1404
City	:	PHILADELPHIA
State	:	PA
Zip	:	19102-3419
Country	:	US
Telephone Number	:	215-772-1031
Fax Number	:	215-772-1032

Provider Business Practice Location Address
First Line	:	1518 WALNUT ST
Second Line	:	SUITE 1404
City	:	PHILADELPHIA
State	:	PA
Zip	:	19102-3419
Country	:	US
Telephone Number	:	215-772-1031
Fax Number	:	215-772-1032

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

Provider Enumeration Date	:	07/08/2006
Last Update Date	:	03/09/2010

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