MEDICARE: LIZZY ENIGWE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	BH000814	PA
2	103K00000X	Behavior Analyst	BH000814	PA

General Provider Information

NPI Number	:	1093103194
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LIZZY ENIGWE

Provider Business Mailing Address
First Line	:	2275 BRIDGE ST BLDG 5
Second Line	:	B-132
City	:	PHILADELPHIA
State	:	PA
Zip	:	19137-2307
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1504 E CLIVEDEN ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19150-3310
Country	:	US
Telephone Number	:	215-939-2118
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/26/2014
Last Update Date	:	12/26/2014

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Directions to “ LIZZY ENIGWE ” Practice Location

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