MEDICARE: PHILLY PSYCHOLOGY LLC

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

General Provider Information

NPI Number	:	1750991949
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHILLY PSYCHOLOGY LLC

Provider Business Mailing Address
First Line	:	255 S 17TH ST STE 1106
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19103-6212
Country	:	US
Telephone Number	:	267-712-9217
Fax Number	:

Provider Business Practice Location Address
First Line	:	255 S 17TH ST STE 1106
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19103-6212
Country	:	US
Telephone Number	:	267-712-9217
Fax Number	:

Authorized Official
Title or Position	:	PSYCHOLOGIST
Name	:	DR. VALERIE BRAUNSTEIN
Credential	:	PSYD
Telephone Number	:	267-712-9217

Provider Enumeration Date	:	08/03/2020
Last Update Date	:	08/03/2020

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