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General NPI Number Information
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NPI Number | 1538365143
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Entity Type | Individual
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Provider Name | LISA GUTTUSO KLENK M.D.
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Gender | Female
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Dates
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Enumeration Date | 06/21/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1420 WALNUT ST SUITE 1412
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City | PHILADELPHIA
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State | PA
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Zip | 19102-4017
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Country | US
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Telephone | 215-735-0218
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Fax | 215-790-1096
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Provider Business Mailing Address
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Address Line | 2206 DELANCEY PL
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City | PHILADELPHIA
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State | PA
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Zip | 19103-6502
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Country | US
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Telephone | 215-732-3762
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Fax | 215-790-1096
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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 | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | MD047322L
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License Number State | PA
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