=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538421474
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REBECCA LYNN PEARL PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2012
-----------------------------------------------------
Last Update Date | 09/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3535 MARKET ST SUITE 3026
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19104-3309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-746-5129
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 100165
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32610-0165
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PS018139
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PY11138
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------