MEDICARE: MARY LOU SCHACK 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
1	103TC0700X	Clinical Psychologist	PS-002366-L	PA

General Provider Information

NPI Number	:	1366626723
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY LOU SCHACK PH.D.

Provider Business Mailing Address
First Line	:	111 PRESIDENTIAL BLVD
Second Line	:	SUITE 237
City	:	BALA CYNWYD
State	:	PA
Zip	:	19004-1008
Country	:	US
Telephone Number	:	610-667-8549
Fax Number	:	610-664-3749

Provider Business Practice Location Address
First Line	:	111 PRESIDENTIAL BLVD
Second Line	:	SUITE 237
City	:	BALA CYNWYD
State	:	PA
Zip	:	19004-1008
Country	:	US
Telephone Number	:	610-667-8549
Fax Number	:	610-664-3749

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/20/2007
Last Update Date	:	03/25/2010

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