Healthcare Provider Details

I. General information

NPI: 1932753035
Provider Name (Legal Business Name): MYLISSA MARY SLANE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2019
Last Update Date: 01/19/2023
Certification Date: 01/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 GRANT AVE
PHILADELPHIA PA
19114-1032
US

IV. Provider business mailing address

734 CHERYL DR
WARMINSTER PA
18974-2135
US

V. Phone/Fax

Practice location:
  • Phone: 215-878-3400
  • Fax:
Mailing address:
  • Phone: 215-817-6849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: