Provider Demographics
NPI:1508083742
Name:BLACK, MARYLYNNE KEMPERMAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARYLYNNE
Middle Name:KEMPERMAN
Last Name:BLACK
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 1:621 HILDEBRANDT ROAD
Mailing Address - Street 2:
Mailing Address - City:PERKIOMENVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18074-9504
Mailing Address - Country:US
Mailing Address - Phone:610-754-7608
Mailing Address - Fax:610-754-7608
Practice Address - Street 1:642 COWPATH ROAD #393
Practice Address - Street 2:
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446
Practice Address - Country:US
Practice Address - Phone:215-361-6959
Practice Address - Fax:215-361-6195
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATPS 029985103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical