Provider Demographics
NPI:1932427515
Name:DEMASTUS, MYRLISS (LCSW)
Entity Type:Individual
Prefix:
First Name:MYRLISS
Middle Name:
Last Name:DEMASTUS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MYRLISS
Other - Middle Name:JANE
Other - Last Name:ESH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:106 JOHNS RD
Mailing Address - Street 2:
Mailing Address - City:CHELTENHAM
Mailing Address - State:PA
Mailing Address - Zip Code:19012-1307
Mailing Address - Country:US
Mailing Address - Phone:215-635-9769
Mailing Address - Fax:
Practice Address - Street 1:521 MOREDON RD
Practice Address - Street 2:
Practice Address - City:HUNTINGDON VALLEY
Practice Address - State:PA
Practice Address - Zip Code:19006-7705
Practice Address - Country:US
Practice Address - Phone:215-938-1130
Practice Address - Fax:215-914-4197
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-06
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0130821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical