=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952725905
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INNER BALANCE PSYCHOLOGY CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2014
-----------------------------------------------------
Last Update Date | 02/11/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 34 E MAIN ST
-----------------------------------------------------
City | MARLTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08053-2157
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-613-0110
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4632
-----------------------------------------------------
City | CHERRY HILL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08034-4632
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-613-0110
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOLOGIST/OWNER
-----------------------------------------------------
Name | DAWN RAFFA
-----------------------------------------------------
Credential | PH.D
-----------------------------------------------------
Telephone | 609-613-0110
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 4889
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------