Provider Demographics
NPI:1184621682
Name:ALONSO, MARIO (PHD)
Entity type:Individual
Prefix:DR
First Name:MARIO
Middle Name:
Last Name:ALONSO
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 1:1011 BROOKSIDE RD
Mailing Address - Street 2:SUITE 305
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18106-9020
Mailing Address - Country:US
Mailing Address - Phone:610-437-2277
Mailing Address - Fax:
Practice Address - Street 1:1011 BROOKSIDE RD
Practice Address - Street 2:SUITE 305
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18106-9020
Practice Address - Country:US
Practice Address - Phone:610-437-2277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS002534L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01522802OtherCAPITAL BLUE CROSS ID
PA089817OtherBLUE SHIELD PROVIDER NUM.