Provider Demographics
NPI:1548330798
Name:KANNERSTEIN, DAVID (PHD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:KANNERSTEIN
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 1:4103 FOUNTAIN GREEN RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE HILL
Mailing Address - State:PA
Mailing Address - Zip Code:19444-1214
Mailing Address - Country:US
Mailing Address - Phone:215-680-4505
Mailing Address - Fax:
Practice Address - Street 1:93 OLD YORK RD
Practice Address - Street 2:SUITE 203
Practice Address - City:JENKINTOWN
Practice Address - State:PA
Practice Address - Zip Code:19046-3925
Practice Address - Country:US
Practice Address - Phone:215-885-3337
Practice Address - Fax:215-885-3090
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPSOO6413-L103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA739644Medicare ID - Type UnspecifiedPSYCHOLOGIST