Healthcare Provider Details

I. General information

NPI: 1295705317
Provider Name (Legal Business Name): SPRINGFIELD PSYCHOLOGICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 12/01/2022
Certification Date: 12/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1489 BALTIMORE PIKE BLDG. 200, SUITE 250
SPRINGFIELD PA
19064-3958
US

IV. Provider business mailing address

1489 BALTIMORE PIKE BLDG. 200, SUITE 250
SPRINGFIELD PA
19064-3958
US

V. Phone/Fax

Practice location:
  • Phone: 610-544-2110
  • Fax: 610-604-9510
Mailing address:
  • Phone: 610-544-2110
  • Fax: 610-604-9510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPS003470-L
License Number StatePA

VIII. Authorized Official

Name: ELISABETH PESCE
Title or Position: SECRETARY
Credential:
Phone: 904-605-4986