Healthcare Provider Details

I. General information

NPI: 1245554674
Provider Name (Legal Business Name): AVIELE MELISSA KOFFLER PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2010
Last Update Date: 03/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 E GERMANTOWN PIKE
PLYMOUTH MEETING PA
19462-1550
US

IV. Provider business mailing address

155 TIMOTHY CIR
RADNOR PA
19087-4647
US

V. Phone/Fax

Practice location:
  • Phone: 610-834-1671
  • Fax:
Mailing address:
  • Phone: 215-901-9512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS016756
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS016756
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberPS016756
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: