Provider Demographics
NPI:1427001361
Name:KOSSMANN, MARC R (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:R
Last Name:KOSSMANN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W EAGLE RD STE 147
Mailing Address - Street 2:
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083-2244
Mailing Address - Country:US
Mailing Address - Phone:610-506-3453
Mailing Address - Fax:
Practice Address - Street 1:101 W EAGLE RD STE 147
Practice Address - Street 2:
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-2244
Practice Address - Country:US
Practice Address - Phone:610-506-3453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS-007828-L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1499690-41Medicaid
605819OtherBLUE SHIELD
605819Medicare ID - Type Unspecified