Provider Demographics
NPI:1144764911
Name:VIRGO, KANEISHA (LSW)
Entity Type:Individual
Prefix:
First Name:KANEISHA
Middle Name:
Last Name:VIRGO
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:YEADON
Mailing Address - State:PA
Mailing Address - Zip Code:19050-2826
Mailing Address - Country:US
Mailing Address - Phone:267-265-8475
Mailing Address - Fax:
Practice Address - Street 1:700 S CHESTER RD
Practice Address - Street 2:
Practice Address - City:SWARTHMORE
Practice Address - State:PA
Practice Address - Zip Code:19081-2224
Practice Address - Country:US
Practice Address - Phone:484-479-3475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-13
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW133867104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker