=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457364614
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FRANK M DATTILIO PH D ABPP PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2006
-----------------------------------------------------
Last Update Date | 12/14/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1251 S CEDAR CREST BLVD SUITE 304 D
-----------------------------------------------------
City | ALLENTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18103-6205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-434-6960
-----------------------------------------------------
Fax | 610-434-6965
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1251 S CEDAR CREST BLVD SUITE 304 D
-----------------------------------------------------
City | ALLENTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18103-6205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-434-6960
-----------------------------------------------------
Fax | 610-434-6965
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. FRANK MARK DATTILIO
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 610-434-6960
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PS006758-L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------