MEDICARE: DR. VIRGINIA M. KOUTSOUROS PSY.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	PS015772	PA

General Provider Information

NPI Number	:	1609982982
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VIRGINIA M. KOUTSOUROS PSY.D.

Provider Business Mailing Address
First Line	:	1006 STRATFORD AVE
Second Line	:
City	:	MELROSE PARK
State	:	PA
Zip	:	19027-3025
Country	:	US
Telephone Number	:	215-782-8972
Fax Number	:	215-635-3087

Provider Business Practice Location Address
First Line	:	5619-25 VINE STREET
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19139-1302
Country	:	US
Telephone Number	:	215-471-2761
Fax Number	:	215-471-2929

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

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	04/10/2013

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