MEDICARE: DR. LAURA WINDHAM PSYD, 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	CW014794	PA

General Provider Information

NPI Number	:	1922325471
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAURA WINDHAM PSYD, LCSW

Provider Business Mailing Address
First Line	:	2005 MARKET ST
Second Line	:	3140
City	:	PHILADELPHIA
State	:	PA
Zip	:	19103-7042
Country	:	US
Telephone Number	:	215-636-9797
Fax Number	:	215-636-9979

Provider Business Practice Location Address
First Line	:	2005 MARKET ST
Second Line	:	3140
City	:	PHILADELPHIA
State	:	PA
Zip	:	19103-7042
Country	:	US
Telephone Number	:	215-636-9797
Fax Number	:	215-636-9979

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

Provider Enumeration Date	:	04/23/2010
Last Update Date	:	04/23/2010

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