Provider Demographics
NPI:1043735582
Name:SIMONETTA, ELIZABETH (BSL)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:SIMONETTA
Suffix:
Gender:F
Credentials:BSL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3890 N SHERMAN STREET EXT
Mailing Address - Street 2:
Mailing Address - City:MOUNT WOLF
Mailing Address - State:PA
Mailing Address - Zip Code:17347-9652
Mailing Address - Country:US
Mailing Address - Phone:210-607-0427
Mailing Address - Fax:
Practice Address - Street 1:3890 N SHERMAN STREET EXT
Practice Address - Street 2:
Practice Address - City:MOUNT WOLF
Practice Address - State:PA
Practice Address - Zip Code:17347-9652
Practice Address - Country:US
Practice Address - Phone:210-607-0427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH002934103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst