1609977404 NPI number — MS. MARY ANN ALEXANDRA GRONCKI MSW LCSW

Table of content: MS. MARY ANN ALEXANDRA GRONCKI MSW LCSW (NPI 1609977404)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609977404 NPI number — MS. MARY ANN ALEXANDRA GRONCKI MSW LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRONCKI
Provider First Name:
MARY ANN
Provider Middle Name:
ALEXANDRA
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MSW LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GRONCKI
Provider Other First Name:
MARY ANN
Provider Other Middle Name:
ALEXANDRA
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSW LCSW
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1609977404
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
713 04 STATE ROAD
Provider Second Line Business Mailing Address:
MARY ANN GRONCKI
Provider Business Mailing Address City Name:
BERWYN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19312
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-292-3276
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3 PAOLI PLAZA
Provider Second Line Business Practice Location Address:
MARY ANN A GRONCKI MSW LCSW SUITE D
Provider Business Practice Location Address City Name:
PAOLI
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-292-3276
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/26/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  CW014618 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 1041C0700X , with the licence number: CW014618 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2318680000 . This is a "BCBS PERSONAL CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1000067657001 . This is a "APS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7902198 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 206938 . This is a "MHN" identifier . This identifiers is of the category "OTHER".