Provider Demographics
NPI:1770575151
Name:SEIDENBERG, GARY HARMON (ED D)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:HARMON
Last Name:SEIDENBERG
Suffix:
Gender:M
Credentials:ED D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9981 WISTARIA ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-1721
Mailing Address - Country:US
Mailing Address - Phone:215-673-4263
Mailing Address - Fax:
Practice Address - Street 1:7901 BUSTLETON AVE
Practice Address - Street 2:SUITE 12
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-3328
Practice Address - Country:US
Practice Address - Phone:215-332-1164
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS003691L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist