MEDICARE: PHYLLIS H GOLTRA 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	103T00000X	Psychologist	PS 006504-L	PA

General Provider Information

NPI Number	:	1467446625
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHYLLIS H GOLTRA PH.D.

Provider Business Mailing Address
First Line	:	1616 WALNUT ST
Second Line	:	SUITE 1616
City	:	PHILADELPHIA
State	:	PA
Zip	:	19103-5313
Country	:	US
Telephone Number	:	215-545-8441
Fax Number	:	215-985-1129

Provider Business Practice Location Address
First Line	:	1616 WALNUT ST
Second Line	:	SUITE 1616
City	:	PHILADELPHIA
State	:	PA
Zip	:	19103-5313
Country	:	US
Telephone Number	:	215-545-8441
Fax Number	:	215-985-1129

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

Provider Enumeration Date	:	09/02/2005
Last Update Date	:	03/24/2009

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