=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235958968
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VICINITY THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2024
-----------------------------------------------------
Last Update Date | 10/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 297 WESTWOOD DR STE 103
-----------------------------------------------------
City | WEST DEPTFORD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08096-3144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-655-4235
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2105 LEXINGTON MEWS
-----------------------------------------------------
City | SWEDESBORO
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08085-1348
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-655-4235
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL PSYCHOLOGIST
-----------------------------------------------------
Name | CHRISTOPH SPANOS
-----------------------------------------------------
Credential | BS, MA, PSYD
-----------------------------------------------------
Telephone | 732-655-4235
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------