Provider Demographics
NPI:1780721605
Name:MOSACK, MARGUERITE A (PHD)
Entity type:Individual
Prefix:DR
First Name:MARGUERITE
Middle Name:A
Last Name:MOSACK
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:BOX 10
Mailing Address - Street 2:239 SCHUYLER AVENUE
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-3333
Mailing Address - Country:US
Mailing Address - Phone:570-283-5580
Mailing Address - Fax:570-283-5583
Practice Address - Street 1:239 SCHUYLER AVENUE
Practice Address - Street 2:SUITE 350
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-3333
Practice Address - Country:US
Practice Address - Phone:570-283-5580
Practice Address - Fax:570-283-5583
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS 005927 L103TB0200X, 103TC0700X, 103TC2200X, 103TF0000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA666689Medicare ID - Type Unspecified