Provider Demographics
NPI:1538496138
Name:FULL SPECTRUM LLC
Entity Type:Organization
Organization Name:FULL SPECTRUM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCY
Authorized Official - Middle Name:A
Authorized Official - Last Name:SHOEMAKER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:215-313-0057
Mailing Address - Street 1:2 BALA PLZ
Mailing Address - Street 2:SUITE 3
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-1501
Mailing Address - Country:US
Mailing Address - Phone:215-313-0057
Mailing Address - Fax:610-520-5205
Practice Address - Street 1:925 ROSCOMMON RD
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-1842
Practice Address - Country:US
Practice Address - Phone:215-313-0057
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-03
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS016629261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPTAN 039191OtherMEDICARE PTAN: 039191