Healthcare Provider Details

I. General information

NPI: 1235340837
Provider Name (Legal Business Name): PATTEY LEEANNE FONG PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1062 E LANCASTER AVE SUITE 12-A
BRYN MAWR PA
19010-1552
US

IV. Provider business mailing address

1062 E LANCASTER AVE SUITE 12-A
BRYN MAWR PA
19010-1552
US

V. Phone/Fax

Practice location:
  • Phone: 610-526-9155
  • Fax:
Mailing address:
  • Phone: 610-526-9155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS-008132-L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: