Provider Demographics
NPI:1306818307
Name:SPORTOLARI, LEDA ROSE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LEDA
Middle Name:ROSE
Last Name:SPORTOLARI
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 1:191 PRESIDENTIAL BLVD
Mailing Address - Street 2:SUITE W10
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-1207
Mailing Address - Country:US
Mailing Address - Phone:610-649-9945
Mailing Address - Fax:610-668-2301
Practice Address - Street 1:191 PRESIDENTIAL BLVD
Practice Address - Street 2:SUITE W10
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-1207
Practice Address - Country:US
Practice Address - Phone:610-649-9945
Practice Address - Fax:610-668-2301
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0136211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
019791Medicare ID - Type Unspecified