Healthcare Provider Details

I. General information

NPI: 1578971750
Provider Name (Legal Business Name): MG THERAPEUTIC SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2014
Last Update Date: 10/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W 6TH ST, SUITE 305 SUITE 305
MEDIA PA
19063-3228
US

IV. Provider business mailing address

100 W 6TH ST, SUITE 305 SUITE 305
MEDIA PA
19063-3228
US

V. Phone/Fax

Practice location:
  • Phone: 484-445-4147
  • Fax: 484-445-4149
Mailing address:
  • Phone: 484-445-4147
  • Fax: 484-445-4149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPS017448
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberPS017448
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS017448
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License NumberPS017448
License Number StatePA

VIII. Authorized Official

Name: DR. MARC GRAMATGES
Title or Position: NEUROPSYCHOLOGIST
Credential: PSYD
Phone: 484-445-4147