Provider Demographics
NPI:1235644253
Name:MCILWAIN, TRISHA A (LCSW)
Entity Type:Individual
Prefix:MS
First Name:TRISHA
Middle Name:A
Last Name:MCILWAIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:WELLSBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16901-1737
Mailing Address - Country:US
Mailing Address - Phone:570-723-0620
Mailing Address - Fax:570-724-0675
Practice Address - Street 1:114 EAST AVE
Practice Address - Street 2:
Practice Address - City:WELLSBORO
Practice Address - State:PA
Practice Address - Zip Code:16901-1737
Practice Address - Country:US
Practice Address - Phone:570-723-0620
Practice Address - Fax:570-724-0675
Is Sole Proprietor?:No
Enumeration Date:2017-12-13
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW132031104100000X
PACW0214171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPENDINGMedicaid