Provider Demographics
NPI:1922268671
Name:REISBOARD, RICHARD JAY
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:JAY
Last Name:REISBOARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 COULTER AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ARDMORE
Mailing Address - State:PA
Mailing Address - Zip Code:19003-2427
Mailing Address - Country:US
Mailing Address - Phone:215-896-8666
Mailing Address - Fax:
Practice Address - Street 1:119 COULTER AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:ARDMORE
Practice Address - State:PA
Practice Address - Zip Code:19003-2427
Practice Address - Country:US
Practice Address - Phone:215-896-8666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS002257-L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA29759Medicare PIN