Provider Demographics
NPI:1215375696
Name:OMARA, LORI (MSS, LCSW, CST)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:OMARA
Suffix:
Gender:F
Credentials:MSS, LCSW, CST
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:
Other - Last Name:KOVELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSS, LCSW
Mailing Address - Street 1:2047 LOCUST ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-5613
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2047 LOCUST ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-5613
Practice Address - Country:US
Practice Address - Phone:267-279-3612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-07
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0180991041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA13874673OtherCAQH
955020OtherAVAILITY
13874673OtherCAQH