Healthcare Provider Details

I. General information

NPI: 1669789913
Provider Name (Legal Business Name): ELISABETH C MAMOURIAN CORONA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELISABETH C MAMOURIAN LCSW

II. Dates (important events)

Enumeration Date: 09/08/2010
Last Update Date: 06/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

283 BUTLER RD # 550
MOUNT GRETNA PA
17064-6085
US

IV. Provider business mailing address

2058 BROAD ST
EAST PETERSBURG PA
17520-1202
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW017740
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: