Healthcare Provider Details

I. General information

NPI: 1407322365
Provider Name (Legal Business Name): JOHN LOGAN DURLAND
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2018
Last Update Date: 10/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1489 BALTIMORE PIKE STE 250
SPRINGFIELD PA
19064-3974
US

IV. Provider business mailing address

4935 PINE ST
PHILADELPHIA PA
19143-1651
US

V. Phone/Fax

Practice location:
  • Phone: 610-544-2110
  • Fax:
Mailing address:
  • Phone: 585-259-8323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS018659
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: