Healthcare Provider Details

I. General information

NPI: 1265503593
Provider Name (Legal Business Name): LINDA GAYLE BROCKWAY MSW, LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 E GERMANTOWN PIKE SUITE 204
PLYMOUTH MEETING PA
19462-1533
US

IV. Provider business mailing address

1921 PANAMA ST
PHILADELPHIA PA
19103-6609
US

V. Phone/Fax

Practice location:
  • Phone: 215-316-2777
  • Fax:
Mailing address:
  • Phone: 215-732-2372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW010951L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: