MEDICARE: AHYOUNG TAE PSYD

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	PS020426	PA

General Provider Information

NPI Number	:	1437930229
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AHYOUNG TAE PSYD

Provider Business Mailing Address
First Line	:	1315 WOLF ST UNIT 2
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19148-2911
Country	:	US
Telephone Number	:	410-921-0048
Fax Number	:

Provider Business Practice Location Address
First Line	:	1315 WOLF ST UNIT 2
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19148-2911
Country	:	US
Telephone Number	:	410-921-0048
Fax Number	:

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

Provider Enumeration Date	:	10/09/2023
Last Update Date	:	07/31/2025

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