Healthcare Provider Details

I. General information

NPI: 1851684906
Provider Name (Legal Business Name): MAIN LINE NEUROPSYCHOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2011
Last Update Date: 03/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 S VALLEY RD SUITE 207
PAOLI PA
19301-1450
US

IV. Provider business mailing address

43 PAOLI PLZ UNIT 1448
PAOLI PA
19301-5044
US

V. Phone/Fax

Practice location:
  • Phone: 610-500-4700
  • Fax:
Mailing address:
  • Phone: 610-500-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS016840
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPS016840
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS016840
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPS016840
License Number StatePA
# 5
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License NumberPS016840
License Number StatePA
# 6
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License NumberPS016840
License Number StatePA
# 7
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPS016840
License Number StatePA

VIII. Authorized Official

Name: DR. JENNIFER BADGLEY
Title or Position: OWNER/NEUROPSYCHOLOGIST
Credential: PHD
Phone: 610-500-4700