=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821234220
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN RACHEL SPAN MSW, LSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2009
-----------------------------------------------------
Last Update Date | 01/06/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 471 S SWEET GUM LN
-----------------------------------------------------
City | LAFAYETTE HILL
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19444-2601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-252-4953
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1709 WATERFORD WAY
-----------------------------------------------------
City | MAPLE GLEN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19002-3157
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-646-1075
-----------------------------------------------------
Fax | 215-827-5219
-----------------------------------------------------
=====================================================
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 | SW011375L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------