Provider Demographics
NPI:1760736508
Name:TREVETHAN, THERESA (PSYD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:TREVETHAN
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 1:249 FOX RUN RD
Mailing Address - Street 2:
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-2222
Mailing Address - Country:US
Mailing Address - Phone:610-363-1488
Mailing Address - Fax:610-363-8273
Practice Address - Street 1:1489 BALTIMORE PIKE
Practice Address - Street 2:SUITE 250
Practice Address - City:SPRINGFIELD
Practice Address - State:PA
Practice Address - Zip Code:19064-3958
Practice Address - Country:US
Practice Address - Phone:610-544-2110
Practice Address - Fax:610-446-3169
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-01
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS017638103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist