MEDICARE: DIVERSIFIED PSYCHOLOGICAL RESOURCES, P.C.

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	PS003688-L	PA
2	103TC0700X	Clinical Psychologist	PS003688-L	PA
3	103G00000X	Clinical Neuropsychologist	PS003688-L	PA

General Provider Information

NPI Number	:	1588711006
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVERSIFIED PSYCHOLOGICAL RESOURCES, P.C.

Provider Business Mailing Address
First Line	:	230 S. BROAD ST.
Second Line	:	SUITE 1005
City	:	PHILADELPHIA
State	:	PA
Zip	:	19102-4105
Country	:	US
Telephone Number	:	215-988-9911
Fax Number	:	215-988-9912

Provider Business Practice Location Address
First Line	:	230 S. BROAD ST.
Second Line	:	SUITE 1005
City	:	PHILADELPHIA
State	:	PA
Zip	:	19102-4105
Country	:	US
Telephone Number	:	215-988-9911
Fax Number	:	215-988-9912

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ROBERT LAWRENCE RIDER
Credential	:	PH.D.
Telephone Number	:	215-988-9911

Provider Enumeration Date	:	01/05/2007
Last Update Date	:	09/16/2022

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