=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740250083
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CROYLE PSYCHOLOGICAL ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1450 SCALP AVE SUITE 209
-----------------------------------------------------
City | JOHNSTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15904-3374
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-266-3196
-----------------------------------------------------
Fax | 814-266-6296
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1450 SCALP AVE SUITE 209
-----------------------------------------------------
City | JOHNSTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15904-3374
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-266-3196
-----------------------------------------------------
Fax | 814-266-6296
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. GRANT W CROYLE
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 814-266-3196
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PS-003270-L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------