Provider Demographics
NPI:1336209576
Name:MARYDINE L LAMB PA
Entity Type:Organization
Organization Name:MARYDINE L LAMB PA
Other - Org Name:MARYDINE L LAMB LCSW
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT OF PA
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARYDINE
Authorized Official - Middle Name:LENTZ
Authorized Official - Last Name:LAMB
Authorized Official - Suffix:
Authorized Official - Credentials:MSW LCSW
Authorized Official - Phone:813-230-2257
Mailing Address - Street 1:PO BOX 2653
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33509-2653
Mailing Address - Country:US
Mailing Address - Phone:941-684-1622
Mailing Address - Fax:941-747-1093
Practice Address - Street 1:2328 MANATEE AVE WEST
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34205
Practice Address - Country:US
Practice Address - Phone:941-684-1622
Practice Address - Fax:941-747-1093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW23751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
09755OtherVALUE OPTIONS
4235987OtherMAGELLAN
4235987OtherMAGELLAN