=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902446644
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHAWNA J PRICE LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2020
-----------------------------------------------------
Last Update Date | 01/10/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 309 W GLENSIDE AVE
-----------------------------------------------------
City | GLENSIDE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19038-3313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-558-5616
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6600 N 3RD ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19126-3120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-722-8718
-----------------------------------------------------
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 | CW021032
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------