Basic Information
| Provider Information | |||||||||
| NPI: | 1902944432 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PELHAM | ||||||||
| FirstName: | MARY | ||||||||
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| Credential: | PSY.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 E OLNEY AVE | ||||||||
| Address2: | SUITE 505 | ||||||||
| City: | PHILA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191202421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152542630 | ||||||||
| FaxNumber: | 2152542599 | ||||||||
| Practice Location | |||||||||
| Address1: | 60 TOWNSHIP LINE RD | ||||||||
| Address2: | MOSS REHAB | ||||||||
| City: | ELKINS PARK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190272220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156636270 | ||||||||
| FaxNumber: | 2156636739 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | PS015401 | PA | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
No ID Information.