Provider Demographics
NPI:1477528198
Name:SMITH, MARYROSE W (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARYROSE
Middle Name:W
Last Name:SMITH
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 1:619 BARRY DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:19064-1503
Mailing Address - Country:US
Mailing Address - Phone:610-328-4331
Mailing Address - Fax:610-328-4331
Practice Address - Street 1:280 N PROVIDENCE RD
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-3527
Practice Address - Country:US
Practice Address - Phone:610-566-3032
Practice Address - Fax:610-328-4331
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0126021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
568889Medicare ID - Type Unspecified