Provider Demographics
NPI:1609982982
Name:KOUTSOUROS, VIRGINIA M (PSYD)
Entity Type:Individual
Prefix:DR
First Name:VIRGINIA
Middle Name:M
Last Name:KOUTSOUROS
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 1:1006 STRATFORD AVE
Mailing Address - Street 2:
Mailing Address - City:MELROSE PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19027-3025
Mailing Address - Country:US
Mailing Address - Phone:215-782-8972
Mailing Address - Fax:215-635-3087
Practice Address - Street 1:5619-25 VINE STREET
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19139-1302
Practice Address - Country:US
Practice Address - Phone:215-471-2761
Practice Address - Fax:215-471-2929
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS015772103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist