Provider Demographics
NPI:1588711006
Name:DIVERSIFIED PSYCHOLOGICAL RESOURCES, P.C.
Entity type:Organization
Organization Name:DIVERSIFIED PSYCHOLOGICAL RESOURCES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:RIDER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:215-988-9911
Mailing Address - Street 1:230 S. BROAD ST.
Mailing Address - Street 2:SUITE 1005
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-4105
Mailing Address - Country:US
Mailing Address - Phone:215-988-9911
Mailing Address - Fax:215-988-9912
Practice Address - Street 1:230 S. BROAD ST.
Practice Address - Street 2:SUITE 1005
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-4105
Practice Address - Country:US
Practice Address - Phone:215-988-9911
Practice Address - Fax:215-988-9912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS003688-L103T00000X, 103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA187309Medicare PIN