Provider Demographics
NPI:1891167748
Name:MALLOUK, THOMAS (PHD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:MALLOUK
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 1:1062 E LANCASTER AVE
Mailing Address - Street 2:
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-1552
Mailing Address - Country:US
Mailing Address - Phone:610-525-4929
Mailing Address - Fax:
Practice Address - Street 1:1062 E LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-1552
Practice Address - Country:US
Practice Address - Phone:610-525-4929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-30
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS003148L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical