Provider Demographics
NPI:1194825810
Name:SUPPLEE, JAMES (PSY D)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:SUPPLEE
Suffix:
Gender:M
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 PADLI PIKE
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355
Mailing Address - Country:US
Mailing Address - Phone:610-251-5430
Mailing Address - Fax:610-296-3788
Practice Address - Street 1:414 PADLI PIKE
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:PA
Practice Address - Zip Code:19355
Practice Address - Country:US
Practice Address - Phone:610-251-5430
Practice Address - Fax:610-296-3788
Is Sole Proprietor?:No
Enumeration Date:2006-09-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS007086L103TC0700X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
P97053Medicare UPIN
072833Medicare ID - Type Unspecified