Healthcare Provider Details

I. General information

NPI: 1124859335
Provider Name (Legal Business Name): OPAL DBT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2024
Last Update Date: 08/09/2024
Certification Date: 08/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1171 LANCASTER AVE STE 100
BERWYN PA
19312-2602
US

IV. Provider business mailing address

1171 LANCASTER AVE STE 100
BERWYN PA
19312-2602
US

V. Phone/Fax

Practice location:
  • Phone: 484-674-6325
  • Fax: 484-674-6325
Mailing address:
  • Phone: 484-674-6324
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. NICOLE DANIELLA CHAIKIN
Title or Position: OWNER/PSYCHOLOGIST
Credential: PSYD
Phone: 484-674-6324