Provider Demographics
NPI:1073623062
Name:KISELICA, MARK S (PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:KISELICA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 COPPERLEAF DR
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18940-1782
Mailing Address - Country:US
Mailing Address - Phone:215-860-5964
Mailing Address - Fax:
Practice Address - Street 1:41 COPPERLEAF DR
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:PA
Practice Address - Zip Code:18940-1782
Practice Address - Country:US
Practice Address - Phone:215-860-5964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00226600101YP2500X
PAPC002162101YP2500X
PAPS008527L103TC0700X
IN20040606103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical