Basic Information
| Provider Information | |||||||||
| NPI: | 1275774549 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLUE | ||||||||
| FirstName: | SHAWN | ||||||||
| MiddleName: | LYNETTE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSY.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 833 CHESTNUT ST | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159558962 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 833 CHESTNUT ST | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159558962 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2009 | ||||||||
| LastUpdateDate: | 09/02/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PS016550 | PA | Y | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | PS016550 | PA | N | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.