Healthcare Provider Details

I. General information

NPI: 1558850008
Provider Name (Legal Business Name): JULIAN RAE MALYS-GORDON PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2018
Last Update Date: 01/10/2024
Certification Date: 01/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

933 E HAVERFORD RD
BRYN MAWR PA
19010-3819
US

IV. Provider business mailing address

1 FRANKLIN TOWN BLVD APT 1703
PHILADELPHIA PA
19103-1248
US

V. Phone/Fax

Practice location:
  • Phone: 484-337-5329
  • Fax:
Mailing address:
  • Phone: 570-574-0826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS019638
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: