Provider Demographics
NPI:1669825261
Name:FASK, DAVID LAURENCE (PHD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LAURENCE
Last Name:FASK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 S 17TH ST
Mailing Address - Street 2:STE. 1010
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-6231
Mailing Address - Country:US
Mailing Address - Phone:484-474-0353
Mailing Address - Fax:
Practice Address - Street 1:255 S 17TH ST
Practice Address - Street 2:STE. 1010
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-6231
Practice Address - Country:US
Practice Address - Phone:484-474-0353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-19
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS018075103T00000X
NJ35SI00568700103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist