MEDICARE: SUPPORTIVE OLDER WOMEN'S NETWORK

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	251S00000X	Community/Behavioral Health Agency
2	104100000X	Social Worker

General Provider Information

NPI Number	:	1245533660
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPPORTIVE OLDER WOMEN'S NETWORK

Provider Business Mailing Address
First Line	:	4100 MAIN ST STE 403
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19127-1623
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4100 MAIN ST STE 403
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19127-1623
Country	:	US
Telephone Number	:	215-487-3000
Fax Number	:	215-487-3111

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MARYPAT B TRACY
Credential	:
Telephone Number	:	215-487-3000

Provider Enumeration Date	:	12/07/2010
Last Update Date	:	01/25/2024

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