Healthcare Provider Details

I. General information

NPI: 1710547799
Provider Name (Legal Business Name): ELISABETH MARIA PETERLEITNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2019
Last Update Date: 01/22/2024
Certification Date: 01/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

488 GROVE ST
WORCESTER MA
01605-1240
US

IV. Provider business mailing address

239 MORELAND ST
WORCESTER MA
01609-1320
US

V. Phone/Fax

Practice location:
  • Phone: 508-755-0333
  • Fax:
Mailing address:
  • Phone: 508-471-7275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number226771
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number126565
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: