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General NPI Number Information
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NPI Number | 1083777239
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Entity Type | Organization
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Legal Business Name | MAIN LINE AFFILIATES
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Dates
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Enumeration Date | 12/19/2006
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Last Update Date | 05/18/2016
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Provider Practice Location Address
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Address Line | 1 RADNOR CORPORATE CTR SUITE 400
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City | RADNOR
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State | PA
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Zip | 19087-4515
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Country | US
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Telephone | 610-254-1450
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Fax |
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Provider Business Mailing Address
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Address Line | 950 E HAVERFORD RD SUITE 110
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City | BRYN MAWR
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State | PA
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Zip | 19010-3850
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Country | US
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Telephone | 610-526-8480
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Fax |
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Authorized Official
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Title or Position | EXEC. VP & CFO
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Name | MR. MICHAEL J BUONGIORNO
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Credential |
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Telephone | 484-337-8481
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number | 237078
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License Number State | PA
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Taxonomy #4
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number | 151081
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License Number State | PA
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Taxonomy #5
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 103TR0400X
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Taxonomy Name | Rehabilitation Psychologist
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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Taxonomy #8
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Taxonomy Code | 2084P0802X
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Taxonomy Name | Addiction Psychiatry Physician
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License Number |
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License Number State |
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Taxonomy #9
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Taxonomy Code | 2084P0804X
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Taxonomy Name | Child & Adolescent Psychiatry Physician
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License Number |
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License Number State |
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Taxonomy #10
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #11
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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