Healthcare Provider Details

I. General information

NPI: 1982008892
Provider Name (Legal Business Name): LISA KOSSUTH MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/21/2014
Last Update Date: 09/05/2025
Certification Date: 09/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 S MAIN ST REAR
OLD FORGE PA
18518-2365
US

IV. Provider business mailing address

1201 REAR SOUTH MAIN ST
OLD FORGE PA
18518
US

V. Phone/Fax

Practice location:
  • Phone: 570-457-4747
  • Fax:
Mailing address:
  • Phone: 570-457-4747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC010339
License Number StatePA

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: