Provider Demographics
NPI:1073684254
Name:FAIRLESS HILLS PSYCHOLOGICAL ASSOCIATES
Entity Type:Organization
Organization Name:FAIRLESS HILLS PSYCHOLOGICAL ASSOCIATES
Other - Org Name:FAIRLESS HILLS PSYCHOLOGICAL ASSOCIATES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:ROSELLA
Authorized Official - Suffix:SR
Authorized Official - Credentials:PHD
Authorized Official - Phone:215-547-5774
Mailing Address - Street 1:333 N OXFORD VALLEY RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FAIRLESS HILLS
Mailing Address - State:PA
Mailing Address - Zip Code:19030-2624
Mailing Address - Country:US
Mailing Address - Phone:215-547-5774
Mailing Address - Fax:215-547-0768
Practice Address - Street 1:333 N OXFORD VALLEY RD
Practice Address - Street 2:SUITE 202
Practice Address - City:FAIRLESS HILLS
Practice Address - State:PA
Practice Address - Zip Code:19030-2624
Practice Address - Country:US
Practice Address - Phone:215-547-5774
Practice Address - Fax:215-547-0768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA000256L103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA127353001Medicaid
PA127353001Medicaid
PAR05539Medicare UPIN