Provider Demographics
NPI:1376594374
Name:WOLBERG, ROSLYN GAIL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ROSLYN
Middle Name:GAIL
Last Name:WOLBERG
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 1:1230 GANTT DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGDON VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19006-3212
Mailing Address - Country:US
Mailing Address - Phone:215-671-0590
Mailing Address - Fax:215-947-0436
Practice Address - Street 1:14500 BUSTLETON AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19116-1188
Practice Address - Country:US
Practice Address - Phone:215-671-0590
Practice Address - Fax:215-947-0436
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS00360L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0049455000OtherMAGELLAN PROVIDER #
PA0049455000OtherMAGELLAN PROVIDER #