Healthcare Provider Details

I. General information

NPI: 1336153766
Provider Name (Legal Business Name): HILLARY S DOMERS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 11/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 MONUMENT RD
PHILA PA
19131-1625
US

IV. Provider business mailing address

4200 MONUMENT RD
PHILA PA
19131-1625
US

V. Phone/Fax

Practice location:
  • Phone: 215-877-2000
  • Fax: 215-581-9195
Mailing address:
  • Phone: 215-877-2000
  • Fax: 215-581-9195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW0077590L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC04796100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: