=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912026717
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | D. WAYNE POPPALARDO, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2007
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 135 S 19TH ST SUITE 240
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19103-4912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-561-4466
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 118 N HADDON AVE
-----------------------------------------------------
City | HADDONFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08033-2306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-428-6644
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST
-----------------------------------------------------
Name | WAYNE POPPALARDO
-----------------------------------------------------
Credential | M.A.
-----------------------------------------------------
Telephone | 856-428-6644
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PS003474L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 00951
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------