Provider Demographics
NPI:1174642813
Name:SHANKEN, PHYLISS (MA)
Entity Type:Individual
Prefix:
First Name:PHYLISS
Middle Name:
Last Name:SHANKEN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2321 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLMAR
Mailing Address - State:PA
Mailing Address - Zip Code:18915-9702
Mailing Address - Country:US
Mailing Address - Phone:215-997-9596
Mailing Address - Fax:215-997-9409
Practice Address - Street 1:2321 N BROAD ST
Practice Address - Street 2:
Practice Address - City:COLMAR
Practice Address - State:PA
Practice Address - Zip Code:18915-9702
Practice Address - Country:US
Practice Address - Phone:215-997-9596
Practice Address - Fax:215-997-9409
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS 003199-L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist