1255636056 NPI number — MS. MARYPAT B TRACY LCSW

Table of content: MS. MARYPAT B TRACY LCSW (NPI 1255636056)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255636056 NPI number — MS. MARYPAT B TRACY LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TRACY
Provider First Name:
MARYPAT
Provider Middle Name:
B
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255636056
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/26/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4100 MAIN ST SUITE 200
Provider Second Line Business Mailing Address:
SUPPORTIVE OLDER WOMEN'S NETWORK
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19127-1623
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-487-3000
Provider Business Mailing Address Fax Number:
215-487-3111

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4100 MAIN ST SUITE 200
Provider Second Line Business Practice Location Address:
SUPPORTIVE OLDER WOMEN'S NETWORK
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19127-1623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-487-3000
Provider Business Practice Location Address Fax Number:
215-487-3111
Provider Enumeration Date:
01/26/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  CW013006 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CW013006 . This is a "PA CLINICAL SOCIAL WORKER LICENSE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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