MEDICARE: MS. ELISE BROMBERG 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	CW012775	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	543509	OTHER	PA	MAGELLAN
2	CW012775	OTHER	PA	LCSW

General Provider Information

NPI Number	:	1578766101
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ELISE BROMBERG LCSW

Provider Business Mailing Address
First Line	:	329 W MOUNT AIRY AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19119-2941
Country	:	US
Telephone Number	:	215-247-6186
Fax Number	:

Provider Business Practice Location Address
First Line	:	329 W MOUNT AIRY AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19119-2941
Country	:	US
Telephone Number	:	215-247-6186
Fax Number	:

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

Provider Enumeration Date	:	06/10/2007
Last Update Date	:	07/08/2007

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