Healthcare Provider Details

I. General information

NPI: 1255305751
Provider Name (Legal Business Name): MICHAEL JOSEPH KIRWIN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

327 NORTH WASHINGTON AVE STE 501
SCRANTON PA
18503
US

IV. Provider business mailing address

RR 1-116K
UNIONDALE PA
18470
US

V. Phone/Fax

Practice location:
  • Phone: 570-342-8973
  • Fax:
Mailing address:
  • Phone: 570-446-0927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS009207L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier001869307001
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerPENNA MEDICAL ASSISTANCE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: