Provider Demographics
NPI:1255636056
Name:TRACY, MARYPAT B (LCSW)
Entity type:Individual
Prefix:MS
First Name:MARYPAT
Middle Name:B
Last Name:TRACY
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 1:4100 MAIN ST SUITE 200
Mailing Address - Street 2:SUPPORTIVE OLDER WOMEN'S NETWORK
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19127-1623
Mailing Address - Country:US
Mailing Address - Phone:215-487-3000
Mailing Address - Fax:215-487-3111
Practice Address - Street 1:4100 MAIN ST SUITE 200
Practice Address - Street 2:SUPPORTIVE OLDER WOMEN'S NETWORK
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19127-1623
Practice Address - Country:US
Practice Address - Phone:215-487-3000
Practice Address - Fax:215-487-3111
Is Sole Proprietor?:No
Enumeration Date:2011-01-26
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0130061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PACW013006OtherPA CLINICAL SOCIAL WORKER LICENSE