Provider Demographics
NPI:1700914249
Name:MARDER, LAURA R (PHD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:R
Last Name:MARDER
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 1:1528 WALNUT ST
Mailing Address - Street 2:SUITE #1203
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-3604
Mailing Address - Country:US
Mailing Address - Phone:215-546-8545
Mailing Address - Fax:215-546-4012
Practice Address - Street 1:1528 WALNUT ST
Practice Address - Street 2:SUITE #1203
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-3604
Practice Address - Country:US
Practice Address - Phone:215-546-8545
Practice Address - Fax:215-546-4012
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS005294L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA595802Medicare UPIN