MEDICARE: MAXWELL JEREMY GREENSPAN LCSW

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	CW018827	PA

General Provider Information

NPI Number	:	1447502844
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAXWELL JEREMY GREENSPAN LCSW

Provider Business Mailing Address
First Line	:	3545 NEW QUEEN ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19129-1634
Country	:	US
Telephone Number	:	973-224-1799
Fax Number	:

Provider Business Practice Location Address
First Line	:	6517 CHESTER AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19142-1718
Country	:	US
Telephone Number	:	215-730-2240
Fax Number	:

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

Provider Enumeration Date	:	10/09/2012
Last Update Date	:	06/01/2016

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