MEDICARE: MS. ELLEN VICKY WEISBERG M.A.

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	103TC1900X	Counseling Psychologist	PS-006488-L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	731333	OTHER	PA	BLUE SHIELD
2	50001372	OTHER	PA	CAPITAL BLUE CROSS

General Provider Information

NPI Number	:	1578591350
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ELLEN VICKY WEISBERG M.A.

Provider Business Mailing Address
First Line	:	325 S 20TH ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19103-6533
Country	:	US
Telephone Number	:	215-985-1947
Fax Number	:	215-985-3633

Provider Business Practice Location Address
First Line	:	325 S 20TH ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19103-6533
Country	:	US
Telephone Number	:	215-985-1947
Fax Number	:	215-985-3633

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

Provider Enumeration Date	:	06/29/2006
Last Update Date	:	07/08/2007

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