Basic Information
| Provider Information | |||||||||
| NPI: | 1770559056 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETRUCCI | ||||||||
| FirstName: | RALPH | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | ED.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 MEDICAL CAMPUS DR | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | LANSDALE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194467205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152557822 | ||||||||
| FaxNumber: | 2152557825 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 MEDICAL CAMPUS DR | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | LANSDALE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194467205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2152335688 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 05/25/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | PS0003012-L | PA | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103T00000X | PS0003012-L | PA | N | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.