=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720466410
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE OFFICES OF DAVID PRYBOCK PHD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2015
-----------------------------------------------------
Last Update Date | 05/13/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 134 S HIGHLAND AVE SUITE 17
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15206-3968
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-952-5348
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 134 S HIGHLAND AVE SUITE 17
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15206-3968
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-952-5348
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PSYCHOLOGIST
-----------------------------------------------------
Name | DR. DAVID PRYBOCK
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 412-952-5348
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PS015862
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------