Provider Demographics
NPI:1780896787
Name:INTOCCIA, MARIANNE E (PHD)
Entity type:Individual
Prefix:
First Name:MARIANNE
Middle Name:E
Last Name:INTOCCIA
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 1:588 FAWNVIEW CIRCLE
Mailing Address - Street 2:
Mailing Address - City:BLUE BELL
Mailing Address - State:PA
Mailing Address - Zip Code:19422-1386
Mailing Address - Country:US
Mailing Address - Phone:215-661-1213
Mailing Address - Fax:
Practice Address - Street 1:426 PENNSYLVANIA AVE.
Practice Address - Street 2:SUITE 101
Practice Address - City:FORT WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:19034
Practice Address - Country:US
Practice Address - Phone:215-628-3440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS004932L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAR07393Medicare UPIN
PAS57144Medicare ID - Type Unspecified