MEDICARE: MRS. MIRIAM INEZ HARTLEY MSW/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	104100000X	Social Worker	SW128734	PA
2	1041C0700X	Clinical Social Worker	CW017835	PA

General Provider Information

NPI Number	:	1588948467
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MIRIAM INEZ HARTLEY MSW/LCSW

Provider Business Mailing Address
First Line	:	3154 MEMORIAL HWY STE 100
Second Line	:
City	:	DALLAS
State	:	PA
Zip	:	18612-9203
Country	:	US
Telephone Number	:	570-674-1155
Fax Number	:	570-674-1156

Provider Business Practice Location Address
First Line	:	1124 TWIN STACKS DR
Second Line	:
City	:	DALLAS
State	:	PA
Zip	:	18612-8505
Country	:	US
Telephone Number	:	570-674-1155
Fax Number	:	570-674-1156

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

Provider Enumeration Date	:	10/10/2011
Last Update Date	:	04/04/2019

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