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NPI Code Detail

MEDICARE: SHONDA NIXON PH.D.

MEDICARE: SHONDA NIXON PH.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103TC0700XClinical PsychologistPS015472PA

General Provider Information

NPI Number : 1003896614
Entity Type Code : Individual
Provider Name (Legal Business Name) : SHONDA NIXON PH.D.
Provider Business Mailing Address
First Line : 4700 WISSAHICKON AVE
Second Line : SUITE 118 BOX 110
City : PHILADELPHIA
State : PA
Zip : 19144-4248
Country : US
Telephone Number : 215-298-0417
Fax Number :
Provider Business Practice Location Address
First Line : 850 N 11TH ST
Second Line :
City : PHILADELPHIA
State : PA
Zip : 19123-1957
Country : US
Telephone Number : 215-769-1590
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/19/2006
Last Update Date : 04/02/2008

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