Provider Demographics
NPI:1508975392
Name:ELLENBERGER, JOANN (LCSW)
Entity Type:Individual
Prefix:
First Name:JOANN
Middle Name:
Last Name:ELLENBERGER
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 1:37 SUSQUENITA HILL RD
Mailing Address - Street 2:
Mailing Address - City:DUNCANNON
Mailing Address - State:PA
Mailing Address - Zip Code:17020-9537
Mailing Address - Country:US
Mailing Address - Phone:717-877-9831
Mailing Address - Fax:717-834-9563
Practice Address - Street 1:37 SUSQUENITA HILL RD
Practice Address - Street 2:
Practice Address - City:DUNCANNON
Practice Address - State:PA
Practice Address - Zip Code:17020-9537
Practice Address - Country:US
Practice Address - Phone:717-877-9831
Practice Address - Fax:717-834-9563
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0138431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA640487OtherMEDICARE PTAN
PA0019616660002Medicaid