=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609274125
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLY MYLES RAY LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2014
-----------------------------------------------------
Last Update Date | 12/16/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3905 FORD RD SUITE 600
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19131-2824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-220-2183
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 335 E ELM ST
-----------------------------------------------------
City | CONSHOHOCKEN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19428-1908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-456-1677
-----------------------------------------------------
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 | CW018397
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------