MEDICARE: DR. CHARLES B WASSERMAN 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	103TC0700X	Clinical Psychologist	PS-005589-L	PA
2	103TC0700X	Clinical Psychologist	B1-0000528	DE

General Provider Information

NPI Number	:	1649240490
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES B WASSERMAN PH.D.

Provider Business Mailing Address
First Line	:	103 S HIGH ST
Second Line	:	SUITE 7
City	:	WEST CHESTER
State	:	PA
Zip	:	19382-3262
Country	:	US
Telephone Number	:	610-429-4355
Fax Number	:	610-429-4355

Provider Business Practice Location Address
First Line	:	103 S HIGH ST
Second Line	:	SUITE 7
City	:	WEST CHESTER
State	:	PA
Zip	:	19382-3262
Country	:	US
Telephone Number	:	610-429-4355
Fax Number	:	610-429-4355

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

Provider Enumeration Date	:	01/25/2006
Last Update Date	:	07/08/2007

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