Healthcare Provider Details

I. General information

NPI: 1962370411
Provider Name (Legal Business Name): DANIELLE EMILY PSILLOS PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2025
Last Update Date: 10/27/2025
Certification Date: 10/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 MONUMENT RD STE 207
BALA CYNWYD PA
19004-1725
US

IV. Provider business mailing address

422 W JEFFERSON ST APT A
MEDIA PA
19063-2658
US

V. Phone/Fax

Practice location:
  • Phone: 818-446-2522
  • Fax:
Mailing address:
  • Phone: 610-564-5133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPS020624
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: