Provider Demographics
NPI:1083861330
Name:OAK LEAF PSYCHOLOGICAL SERVICES, LLC
Entity Type:Organization
Organization Name:OAK LEAF PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:610-783-5000
Mailing Address - Street 1:1 DAVIS RD., STE. 235
Mailing Address - Street 2:PO BOX 35
Mailing Address - City:VALLEY FORGE
Mailing Address - State:PA
Mailing Address - Zip Code:19481-0035
Mailing Address - Country:US
Mailing Address - Phone:610-783-5000
Mailing Address - Fax:610-783-0525
Practice Address - Street 1:1 DAVIS RD., STE. 235
Practice Address - Street 2:
Practice Address - City:VALLEY FORGE
Practice Address - State:PA
Practice Address - Zip Code:19482
Practice Address - Country:US
Practice Address - Phone:610-783-5000
Practice Address - Fax:610-783-0525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS015097261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health