Provider Demographics
NPI:1902868318
Name:FANTASIA-DAVIS, ROWENA CARMELA (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROWENA
Middle Name:CARMELA
Last Name:FANTASIA-DAVIS
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 1:480 PATHFINDER DR
Mailing Address - Street 2:
Mailing Address - City:BIRDSBORO
Mailing Address - State:PA
Mailing Address - Zip Code:19508-9489
Mailing Address - Country:US
Mailing Address - Phone:610-779-4615
Mailing Address - Fax:610-779-4661
Practice Address - Street 1:480 PATHFINDER DR
Practice Address - Street 2:
Practice Address - City:BIRDSBORO
Practice Address - State:PA
Practice Address - Zip Code:19508-9489
Practice Address - Country:US
Practice Address - Phone:610-779-4615
Practice Address - Fax:610-779-4661
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS007993L103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01113102OtherCAPBC PIN
PA464757OtherVALUE OPTIONS PIN
PA464757OtherVALUE OPTIONS PIN