Provider Demographics
NPI:1174678296
Name:DEMILLE, LAUREN ALYSSA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LAUREN
Middle Name:ALYSSA
Last Name:DEMILLE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4634 SPRUCE ST
Mailing Address - Street 2:FIRST FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19139
Mailing Address - Country:US
Mailing Address - Phone:215-747-5445
Mailing Address - Fax:
Practice Address - Street 1:10125 VERREE RD
Practice Address - Street 2:SUITE 304 JFCS
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19116
Practice Address - Country:US
Practice Address - Phone:215-673-0100
Practice Address - Fax:215-934-6284
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0154901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1000008810825Medicaid
PA1000008810009Medicaid