Healthcare Provider Details

I. General information

NPI: 1902868318
Provider Name (Legal Business Name): ROWENA CARMELA FANTASIA-DAVIS PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 PATHFINDER DR
BIRDSBORO PA
19508-9489
US

IV. Provider business mailing address

480 PATHFINDER DR
BIRDSBORO PA
19508-9489
US

V. Phone/Fax

Practice location:
  • Phone: 610-779-4615
  • Fax: 610-779-4661
Mailing address:
  • Phone: 610-779-4615
  • Fax: 610-779-4661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPS007993L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: