Provider Demographics
NPI:1558564724
Name:VIVONA, JEANINE MARIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEANINE
Middle Name:MARIE
Last Name:VIVONA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 PELHAM RD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-2624
Mailing Address - Country:US
Mailing Address - Phone:215-843-7368
Mailing Address - Fax:
Practice Address - Street 1:11 BALA AVE
Practice Address - Street 2:
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-3201
Practice Address - Country:US
Practice Address - Phone:215-570-4947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS-008618-L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical