Healthcare Provider Details

I. General information

NPI: 1558740456
Provider Name (Legal Business Name): ELIZABETH ANN MUTTER D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2015
Last Update Date: 09/09/2020
Certification Date: 09/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2710 SCHOENERSVILLE RD
BETHLEHEM PA
18017-3574
US

IV. Provider business mailing address

2100 MACK BLVD FL 4
ALLENTOWN PA
18103-5622
US

V. Phone/Fax

Practice location:
  • Phone: 610-297-7500
  • Fax: 610-297-7533
Mailing address:
  • Phone: 484-884-0720
  • Fax: 484-884-0628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2020-00192
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberOS020127
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberOS020127
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: