Provider Demographics
NPI:1093103194
Name:ENIGWE, LIZZY
Entity Type:Individual
Prefix:
First Name:LIZZY
Middle Name:
Last Name:ENIGWE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2275 BRIDGE ST BLDG 5
Mailing Address - Street 2:B-132
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19137-2307
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1504 E CLIVEDEN ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19150-3310
Practice Address - Country:US
Practice Address - Phone:215-939-2118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-26
Last Update Date:2014-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH000814101YM0800X, 103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health