Basic Information
Provider Information | |||||||||
NPI: | 1144250465 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | IACOVELLI | ||||||||
FirstName: | ELISABETH | ||||||||
MiddleName: | ANNE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.S.W. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SMITH | ||||||||
OtherFirstName: | ELISABETH | ||||||||
OtherMiddleName: | ANNE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.S.W. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1805 PENNLAND CT | ||||||||
Address2: |   | ||||||||
City: | LANSDALE | ||||||||
State: | PA | ||||||||
PostalCode: | 194464332 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2672103162 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 807 LAWN AVE | ||||||||
Address2: |   | ||||||||
City: | SELLERSVILLE | ||||||||
State: | PA | ||||||||
PostalCode: | 189601549 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2152576551 | ||||||||
FaxNumber: | 2152579347 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/03/2006 | ||||||||
LastUpdateDate: | 08/25/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | CW015211 | PA | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 171M00000X | CW015211 | PA | N |   | Other Service Providers | Case Manager/Care Coordinator |   |
ID Information
ID | Type | State | Issuer | Description | 1012718240002 | 05 | PA |   | MEDICAID |