MEDICARE: STACY GOLBORO HANAK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	CW017974	PA

General Provider Information

NPI Number	:	1073930418
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACY GOLBORO HANAK

Provider Business Mailing Address
First Line	:	2100 ARCH ST 5
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19103-1300
Country	:	US
Telephone Number	:	267-256-2115
Fax Number	:

Provider Business Practice Location Address
First Line	:	191 PRESIDENTIAL BLVD STE C129
Second Line	:
City	:	BALA CYNWYD
State	:	PA
Zip	:	19004-1216
Country	:	US
Telephone Number	:	484-334-8211
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/24/2014
Last Update Date	:	01/26/2021

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