MEDICARE: PHILIP E SUNDSTROM M.A.,LIC PSYCHOLOGIS

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	257	WV

General Provider Information

NPI Number	:	1750594115
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILIP E SUNDSTROM M.A.,LIC PSYCHOLOGIS

Provider Business Mailing Address
First Line	:	209 W MAPLE AVE
Second Line	:
City	:	FAYETTEVILLE
State	:	WV
Zip	:	25840-1413
Country	:	US
Telephone Number	:	304-574-2100
Fax Number	:	304-574-2151

Provider Business Practice Location Address
First Line	:	209 W MAPLE AVE
Second Line	:
City	:	FAYETTEVILLE
State	:	WV
Zip	:	25840-1413
Country	:	US
Telephone Number	:	304-574-2100
Fax Number	:	304-574-2151

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

Provider Enumeration Date	:	05/08/2007
Last Update Date	:	07/08/2007

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