Provider Demographics
NPI:1194065524
Name:MAIN LINE NEUROPSYCHOLOGY, PLLC
Entity type:Organization
Organization Name:MAIN LINE NEUROPSYCHOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BADGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:610-500-4700
Mailing Address - Street 1:101 LINDENWOOD DR STE 225
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-1762
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 LINDENWOOD DR
Practice Address - Street 2:SUITE 225
Practice Address - City:MALVERN
Practice Address - State:PA
Practice Address - Zip Code:19355-1755
Practice Address - Country:US
Practice Address - Phone:610-500-4700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-21
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS016840103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty