Healthcare Provider Details

I. General information

NPI: 1164087227
Provider Name (Legal Business Name): ANTHONY VINCENT LOCASCIO III MA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2019
Last Update Date: 05/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 OLD WEST CHESTER PIKE
HAVERTOWN PA
19083-2712
US

IV. Provider business mailing address

126 ARGYLE RD APT B8
ARDMORE PA
19003-2831
US

V. Phone/Fax

Practice location:
  • Phone: 484-454-8700
  • Fax:
Mailing address:
  • Phone: 610-220-7819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC011282
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: