Healthcare Provider Details

I. General information

NPI: 1407373483
Provider Name (Legal Business Name): LIDIAYBETH C MARRON LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2017
Last Update Date: 08/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 S 16TH ST
PHILADELPHIA PA
19102-4908
US

IV. Provider business mailing address

1208 N 4TH ST UNIT 2
PHILADELPHIA PA
19122-4404
US

V. Phone/Fax

Practice location:
  • Phone: 215-732-8244
  • Fax: 215-732-8454
Mailing address:
  • Phone: 484-472-3283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberPA133822
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: