Provider Demographics
NPI:1730252529
Name:MYRTETUS, DALE P (LCSW)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:P
Last Name:MYRTETUS
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 1:1045 KASMIR AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BENSALEM
Mailing Address - State:PA
Mailing Address - Zip Code:19020-4520
Mailing Address - Country:US
Mailing Address - Phone:215-244-2624
Mailing Address - Fax:
Practice Address - Street 1:1045 KASMIR AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:BENSALEM
Practice Address - State:PA
Practice Address - Zip Code:19020-4520
Practice Address - Country:US
Practice Address - Phone:215-244-2624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0123171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA11529542OtherCAQH
PA2124455000OtherINDEPENCE BLUE CROSS
PA438269OtherKEYSTONE EAST
PA464611OtherVALUE OPTIONS MIS#
PA2124455000OtherINDEPENCE BLUE CROSS