Provider Demographics
NPI:1114383932
Name:ARBOR GROVE PSYCHOLOGICAL SERVICES
Entity Type:Organization
Organization Name:ARBOR GROVE PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:BACON
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:215-300-8111
Mailing Address - Street 1:118 SOUTH BELLEVUE AVE
Mailing Address - Street 2:
Mailing Address - City:LANGHORNE
Mailing Address - State:PA
Mailing Address - Zip Code:19047
Mailing Address - Country:US
Mailing Address - Phone:215-947-0424
Mailing Address - Fax:
Practice Address - Street 1:118 SOUTH BELLEVUE AVE
Practice Address - Street 2:
Practice Address - City:LANGHORNE
Practice Address - State:PA
Practice Address - Zip Code:19047
Practice Address - Country:US
Practice Address - Phone:215-947-0424
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-08
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health