Healthcare Provider Details

I. General information

NPI: 1225122658
Provider Name (Legal Business Name): MARJORIE W REAGAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 MARKET ST
BANGOR PA
18013-1901
US

IV. Provider business mailing address

1026 STATE PARK RD
WIND GAP PA
18091-9784
US

V. Phone/Fax

Practice location:
  • Phone: 610-588-9109
  • Fax: 610-588-5016
Mailing address:
  • Phone: 610-863-6170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW015332
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: