Healthcare Provider Details

I. General information

NPI: 1649296559
Provider Name (Legal Business Name): KATHELEEN REIDY PH D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 WALNUT ST SUITE 1700
PHILADELPHIA PA
19107-4719
US

IV. Provider business mailing address

1630 RIVERSIDE DRIVE
TRENTON NJ
08618-5837
US

V. Phone/Fax

Practice location:
  • Phone: 215-717-2716
  • Fax: 215-545-8496
Mailing address:
  • Phone: 609-947-1116
  • Fax: 215-545-8496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS005184L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number35SI00404500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: