Healthcare Provider Details

I. General information

NPI: 1972499465
Provider Name (Legal Business Name): DISTRACTED THERAPIST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2025
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 N PARK RD
WYOMISSING PA
19610-2920
US

IV. Provider business mailing address

504 N PARK RD
WYOMISSING PA
19610-2920
US

V. Phone/Fax

Practice location:
  • Phone: 484-929-0688
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: LISA YOUNG
Title or Position: OWNER/PSYCHOTHERAPIST
Credential: LCSW
Phone: 215-313-0086