Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 103G00000X | Clinical Neuropsychologist | | | | No |
| 2 | 103T00000X | Psychologist | | | | No |
| 3 | 261QR0405X | Clinic/Center | Rehabilitation, Substance Use Disorder | 237078 | PENNSYLVANIA | No |
| 4 | 261QR0405X | Clinic/Center | Rehabilitation, Substance Use Disorder | 151081 | PENNSYLVANIA | No |
| 5 | 103TC0700X | Psychologist | Clinical | | | No |
| 6 | 103TR0400X | Psychologist | Rehabilitation | | | No |
| 7 | 101YA0400X | Counselor | Addiction (Substance Use Disorder) | | | No |
| 8 | 2084P0802X | Psychiatry & Neurology | Addiction Psychiatry | | | No |
| 9 | 2084P0804X | Psychiatry & Neurology | Child & Adolescent Psychiatry | | | No |
| 10 | 261QM0850X | Clinic/Center | Adult Mental Health | | | No |
| 11 | 2084P0800X | Psychiatry & Neurology | Psychiatry | | | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | 2089835 | OTHER | | CIGNA - CAD EXTON |
| 2 | 087890 | MEDICARE ID-TYPE UNSPECIFIED | | |
| 3 | 280110000 | OTHER | | MAGELLAN - CAD DREXEL HIL |
| 4 | 293195 | OTHER | | VALUEOPTIONS - MLA |
| 5 | 7985197 | OTHER | | AETNA PPO - MLA |
| 6 | 1007726370011 | MEDICAID | PENNSYLVANIA | |
| 7 | 101825 | OTHER | | UNITED - CAD ADOLESCENT |
| 8 | 231200000 | OTHER | | MAGELLAN - CAD EXTON |
| 9 | 2983910 | OTHER | | AETNA HMO - CAD EXTON |
| 10 | 101824 | OTHER | | UNITED - CAD ADULT IOP |
| 11 | 2089834 | OTHER | | CIGNA - CAD DREXEL HILL |
| 12 | 0470009 | OTHER | | AETNA HMO - BMR PSYCH |
| 13 | 0664704000 | OTHER | | IBC - BMR PSYCH ASSOC |
| 14 | 101823 | OTHER | | UNITED - CAD - ADULT PHP |
| 15 | 2317419000 | OTHER | | IBC - MLA |
| 16 | 471443000 | OTHER | | MAGELLAN - MLA |
| 17 | 2983830 | OTHER | | AETNA HMO - CAD DREX HILL |
