Healthcare Provider Details

I. General information

NPI: 1639512270
Provider Name (Legal Business Name): JENNIFER ANN LYRISTIS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2013
Last Update Date: 04/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

283 BUTLER RD
MOUNT GRETNA PA
17064-6085
US

IV. Provider business mailing address

1159 STONE HILL RD
CONESTOGA PA
17516-9634
US

V. Phone/Fax

Practice location:
  • Phone: 717-273-8871
  • Fax:
Mailing address:
  • Phone: 717-399-3442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW017549
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: