Provider Demographics
NPI:1679764641
Name:RADICH, CAROL ANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:ANN
Last Name:RADICH
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 1:914 SAINT ANDREWS DR
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-3157
Mailing Address - Country:US
Mailing Address - Phone:610-644-3394
Mailing Address - Fax:
Practice Address - Street 1:914 SAINT ANDREWS DR
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:PA
Practice Address - Zip Code:19355-3157
Practice Address - Country:US
Practice Address - Phone:610-644-3394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS003945L103T00000X, 103TA0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging