Provider Demographics
NPI:1336109230
Name:KNUDSEN, DOMENICA M
Entity Type:Individual
Prefix:
First Name:DOMENICA
Middle Name:M
Last Name:KNUDSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DONNA
Other - Middle Name:M
Other - Last Name:KNUDSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSY D
Mailing Address - Street 1:280 N PROVIDENCE RD
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-3527
Mailing Address - Country:US
Mailing Address - Phone:610-565-6843
Mailing Address - Fax:
Practice Address - Street 1:280 N PROVIDENCE RD
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-3527
Practice Address - Country:US
Practice Address - Phone:610-565-6843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS008547L103TC0700X
DEB1-0000679103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE100025867Medicare ID - Type UnspecifiedMEDICARE LICENSE
PA03663Medicare ID - Type UnspecifiedMEDICARE LICENSE