Provider Demographics
NPI:1144288671
Name:FRIED-CASSORLA, MARTHA JANE (PHD)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:JANE
Last Name:FRIED-CASSORLA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 OLD YORK RD
Mailing Address - Street 2:SUITE 405
Mailing Address - City:JENKINTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19046-3706
Mailing Address - Country:US
Mailing Address - Phone:215-576-8430
Mailing Address - Fax:
Practice Address - Street 1:261 OLD YORK RD
Practice Address - Street 2:SUITE 405
Practice Address - City:JENKINTOWN
Practice Address - State:PA
Practice Address - Zip Code:19046-3706
Practice Address - Country:US
Practice Address - Phone:215-576-8430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS-003724-L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PW179139OtherBLUE SHIELD
PA222714179OtherTAX ID NUMBER
PW179139OtherBLUE SHIELD