=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548924210
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHEN JAMES CALVARESE LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2021
-----------------------------------------------------
Last Update Date | 12/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3900 WOODLAND AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19104-4551
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-823-5800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 218 N EASTON RD APT E26
-----------------------------------------------------
City | GLENSIDE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19038-4141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-844-6598
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | CW025303
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | SW135169
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------