Provider Demographics
NPI:1033667548
Name:MICELI, ELIZABETH S (PSYD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:S
Last Name:MICELI
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 858
Mailing Address - Street 2:MC A410
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-0858
Mailing Address - Country:US
Mailing Address - Phone:800-243-1455
Mailing Address - Fax:
Practice Address - Street 1:905 W GOVERNOR RD STE 200
Practice Address - Street 2:
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-2310
Practice Address - Country:US
Practice Address - Phone:717-531-7235
Practice Address - Fax:717-531-0067
Is Sole Proprietor?:No
Enumeration Date:2016-09-13
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS018864103TC0700X, 103TC2200X
103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1285628552OtherAGENCIES