=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750764361
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LINDSEY SUSAN HARVILLA D.O.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2015
-----------------------------------------------------
Last Update Date | 07/18/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4641 ROOSEVELT BLVD
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19124-2343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-831-4577
-----------------------------------------------------
Fax | 215-831-5042
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4641 ROOSEVELT BLVD RM 232 E
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19124-2343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-831-4577
-----------------------------------------------------
Fax | 215-831-5042
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | OS019504
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------