Healthcare Provider Details

I. General information

NPI: 1033363437
Provider Name (Legal Business Name): MARIA A MIYAMOTO MSW, LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2008
Last Update Date: 11/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 MARKET ST
CAMDEN NJ
08102-1526
US

IV. Provider business mailing address

101 PHEASANT FIELD LN
MOORESTOWN NJ
08057-1431
US

V. Phone/Fax

Practice location:
  • Phone: 856-541-1700
  • Fax:
Mailing address:
  • Phone: 856-439-0586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number44SL05519400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: