Healthcare Provider Details

I. General information

NPI: 1528378676
Provider Name (Legal Business Name): MARY ALYCE RENSA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2010
Last Update Date: 10/07/2010
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

2000 OLD WEST CHESTER PIKE
HAVERTOWN PA
19083-2712
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC000783
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: