Provider Demographics
NPI:1326019092
Name:GENETTA, ANN H (PSYD)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:H
Last Name:GENETTA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 ELKDALE RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN UNIVERSITY
Mailing Address - State:PA
Mailing Address - Zip Code:19352-9730
Mailing Address - Country:US
Mailing Address - Phone:484-356-6117
Mailing Address - Fax:
Practice Address - Street 1:404 ELKDALE RD
Practice Address - Street 2:
Practice Address - City:LINCOLN UNIVERSITY
Practice Address - State:PA
Practice Address - Zip Code:19352-9730
Practice Address - Country:US
Practice Address - Phone:484-356-6117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEB10000646103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DES49534Medicare UPIN
DE017331C90Medicare PIN