Provider Demographics
NPI:1932496122
Name:DIVITO, JILL ASHLEY (LPC)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:ASHLEY
Last Name:DIVITO
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12634 ANGLING RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:EDINBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16412-1369
Mailing Address - Country:US
Mailing Address - Phone:814-734-7094
Mailing Address - Fax:814-734-3080
Practice Address - Street 1:12634 ANGLING RD
Practice Address - Street 2:SUITE E
Practice Address - City:EDINBORO
Practice Address - State:PA
Practice Address - Zip Code:16412-1369
Practice Address - Country:US
Practice Address - Phone:814-734-7094
Practice Address - Fax:814-734-3080
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC005868101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional