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General NPI Number Information
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NPI Number | 1093090474
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Entity Type | Individual
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Provider Name | MICHAEL ANDREW WILLISTON PSY.D.
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Gender | Male
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Dates
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Enumeration Date | 10/17/2011
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Last Update Date | 01/13/2025
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Provider Practice Location Address
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Address Line | 4000 NEXUS DR STE NE3-100
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City | WILMINGTON
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State | DE
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Zip | 19803-3000
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Country | US
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Telephone | 302-320-9771
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Fax | 302-623-7964
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Provider Business Mailing Address
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Address Line | 112 N BROAD ST
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City | PHILADELPHIA
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State | PA
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Zip | 19102-1512
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Country | US
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Telephone | 215-568-0860
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | B1-0011487
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License Number State | DE
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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 | PS017269
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License Number State | PA
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