Provider Demographics
NPI:1245840446
Name:MEYER, THEODORE GROVER
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:GROVER
Last Name:MEYER
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 1:108 UPLAND TER
Mailing Address - Street 2:
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-3127
Mailing Address - Country:US
Mailing Address - Phone:610-999-9157
Mailing Address - Fax:
Practice Address - Street 1:2566 FRANKFORD AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19125-1743
Practice Address - Country:US
Practice Address - Phone:215-397-2943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-03
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH4686101YP2500X
PAPC012471101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty