=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649376443
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIND OF THE ATHLETE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2006
-----------------------------------------------------
Last Update Date | 09/05/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3400 BATH PIKE SUITE 302
-----------------------------------------------------
City | BETHLEHEM
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18017-2466
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-867-7770
-----------------------------------------------------
Fax | 610-867-7778
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3400 BATH PIKE SUITE 302
-----------------------------------------------------
City | BETHLEHEM
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18017-2466
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-867-7770
-----------------------------------------------------
Fax | 610-867-7778
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. ABBY SPENCER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 610-837-6616
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PS015497
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------