Healthcare Provider Details

I. General information

NPI: 1407278492
Provider Name (Legal Business Name): ELIZABETH INCORVIA LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2014
Last Update Date: 02/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25550 CHAGRIN BLVD STE 200
BEACHWOOD OH
44122-4640
US

IV. Provider business mailing address

25550 CHAGRIN BLVD STE 200
BEACHWOOD OH
44122-4640
US

V. Phone/Fax

Practice location:
  • Phone: 651-645-5323
  • Fax:
Mailing address:
  • Phone: 651-645-5323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberM.1300011
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberA10303
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: