MEDICARE: MS. MARYPAT B TRACY LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	CW013006	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CW013006	OTHER	PA	PA CLINICAL SOCIAL WORKER LICENSE

General Provider Information

NPI Number	:	1255636056
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARYPAT B TRACY LCSW

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

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

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/26/2011
Last Update Date	:	01/26/2011

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