Basic Information
Provider Information | |||||||||
NPI: | 1265696801 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MECKBACH | ||||||||
FirstName: | ELISE | ||||||||
MiddleName: | KATHRYN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BETTOZZI | ||||||||
OtherFirstName: | ELISE | ||||||||
OtherMiddleName: | KATHRYN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 7 DOCK HILL RD | ||||||||
Address2: |   | ||||||||
City: | MIDDLEBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 178428910 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5708372123 | ||||||||
FaxNumber: | 5708372185 | ||||||||
Practice Location | |||||||||
Address1: | 1205 RIVER AVE FL 2 | ||||||||
Address2: |   | ||||||||
City: | WILLIAMSPORT | ||||||||
State: | PA | ||||||||
PostalCode: | 177013724 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5703264118 | ||||||||
FaxNumber: | 5703265533 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/14/2008 | ||||||||
LastUpdateDate: | 04/26/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/26/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | PC005997 | PA | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | PC005997 | PA | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
ID | Type | State | Issuer | Description | 1035098140001 | 05 | PA |   | MEDICAID |