Provider Demographics
NPI:1609499243
Name:MAVINDIDZE, ELIZABETH RANGANAI (LCSW)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:RANGANAI
Last Name:MAVINDIDZE
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 1:3444 BARN RD
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502-7403
Mailing Address - Country:US
Mailing Address - Phone:610-772-3734
Mailing Address - Fax:
Practice Address - Street 1:WAKEMED HEALTH AND HOSPITALS
Practice Address - Street 2:3000 NEW BERN AVENUE
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610
Practice Address - Country:US
Practice Address - Phone:919-350-7722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-18
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC010695104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker