Provider Demographics
NPI:1295883320
Name:DEMATATIS, CHRIS GUS (CHRIS DEMATATIS)
Entity type:Individual
Prefix:DR
First Name:CHRIS
Middle Name:GUS
Last Name:DEMATATIS
Suffix:
Gender:M
Credentials:CHRIS DEMATATIS
Other - Prefix:DR
Other - First Name:CHRIS
Other - Middle Name:GUS
Other - Last Name:DEMATATIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CHRIS DEMATATIS
Mailing Address - Street 1:191 PRESIDENTIAL BLVD
Mailing Address - Street 2:SUITE 124
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-1207
Mailing Address - Country:US
Mailing Address - Phone:610-667-5829
Mailing Address - Fax:610-667-3438
Practice Address - Street 1:191 PRESIDENTIAL BLVD
Practice Address - Street 2:SUITE 124
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-1207
Practice Address - Country:US
Practice Address - Phone:610-667-5829
Practice Address - Fax:610-667-3438
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS-003889-L103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPS-003889-LOtherSTATE LICENSE NUMBER
PA183-766Medicare ID - Type UnspecifiedMEDICARE