MEDICARE: MITCHELL PSYCHOLOGICAL SERVICES INC

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	PS005301L	PA

General Provider Information

NPI Number	:	1568754018
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MITCHELL PSYCHOLOGICAL SERVICES INC

Provider Business Mailing Address
First Line	:	5932 PULASKI AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19144-3823
Country	:	US
Telephone Number	:	215-849-7945
Fax Number	:

Provider Business Practice Location Address
First Line	:	5932 PULASKI AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19144-3823
Country	:	US
Telephone Number	:	215-849-7945
Fax Number	:

Authorized Official
Title or Position	:	BILLING
Name	:	MRS. MELISSA R ROMANELLI
Credential	:
Telephone Number	:	724-387-2455

Provider Enumeration Date	:	05/03/2011
Last Update Date	:	05/03/2011

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