Healthcare Provider Details

I. General information

NPI: 1568180958
Provider Name (Legal Business Name): MARK VINCENT VERSELLA JR. PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2022
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 WHARTON ST
PHILADELPHIA PA
19147-4509
US

IV. Provider business mailing address

1215 WHARTON ST
PHILADELPHIA PA
19147-4509
US

V. Phone/Fax

Practice location:
  • Phone: 215-948-2750
  • Fax:
Mailing address:
  • Phone: 215-948-2750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number35SI00687800
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License NumberPS019662
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number35SI00687800
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPS019662
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: