=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003380395
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIA DRVOSHANOV PSYD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2019
-----------------------------------------------------
Last Update Date | 01/19/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1518 WALNUT ST STE 607
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19102-3404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-606-9076
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 910 CHERRY ST APT 707
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19107-2469
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-606-9076
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PA018535
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------