=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457583833
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY HEALTH PSYCHOLOGY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2009
-----------------------------------------------------
Last Update Date | 06/10/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 506 W MOUNT AIRY AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19119-2948
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-237-5444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 506 W MOUNT AIRY AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19119-2948
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-237-5444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MBR
-----------------------------------------------------
Name | BRETT BOYER
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 610-237-5444
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------