Healthcare Provider Details

I. General information

NPI: 1639489289
Provider Name (Legal Business Name): EMILY M WEISS PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2010
Last Update Date: 10/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1845 WALNUT STREET SUITE 945
PHILADELPHIA PA
19103-4709
US

IV. Provider business mailing address

4910 OSAGE AVENUE
PHILADELPHIA PA
19143-1609
US

V. Phone/Fax

Practice location:
  • Phone: 267-702-3027
  • Fax:
Mailing address:
  • Phone: 267-304-3027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS016857
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberPS016857
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: