MEDICARE: MS. GRACE A. PENMAN L.C.S.W.

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	CW013803	PA

General Provider Information

NPI Number	:	1770791857
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. GRACE A. PENMAN L.C.S.W.

Provider Business Mailing Address
First Line	:	1227 MAPLE ST
Second Line	:
City	:	BLOOMSBURG
State	:	PA
Zip	:	17815-9432
Country	:	US
Telephone Number	:	570-594-9615
Fax Number	:	570-784-9240

Provider Business Practice Location Address
First Line	:	1227 MAPLE ST
Second Line	:
City	:	BLOOMSBURG
State	:	PA
Zip	:	17815-9432
Country	:	US
Telephone Number	:	570-594-9615
Fax Number	:	570-784-9240

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

Provider Enumeration Date	:	05/20/2007
Last Update Date	:	07/09/2007

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