Provider Demographics
NPI:1932753035
Name:SLANE, MYLISSA MARY (PHD)
Entity Type:Individual
Prefix:
First Name:MYLISSA
Middle Name:MARY
Last Name:SLANE
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 1:734 CHERYL DR
Mailing Address - Street 2:
Mailing Address - City:WARMINSTER
Mailing Address - State:PA
Mailing Address - Zip Code:18974-2135
Mailing Address - Country:US
Mailing Address - Phone:215-817-6849
Mailing Address - Fax:
Practice Address - Street 1:2801 GRANT AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-1032
Practice Address - Country:US
Practice Address - Phone:215-878-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-26
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent