Provider Demographics
NPI:1306817291
Name:MALE, THERON C (PHD)
Entity Type:Individual
Prefix:DR
First Name:THERON
Middle Name:C
Last Name:MALE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 W CHESTER PIKE
Mailing Address - Street 2:STE D-2
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19382-7783
Mailing Address - Country:US
Mailing Address - Phone:610-692-2092
Mailing Address - Fax:610-692-2863
Practice Address - Street 1:1515 W CHESTER PIKE
Practice Address - Street 2:STE D-2
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19382-7783
Practice Address - Country:US
Practice Address - Phone:610-692-2092
Practice Address - Fax:610-692-2863
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS000850L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPS000850LMedicaid
PAMA29562Medicare ID - Type Unspecified