Provider Demographics
NPI:1982008892
Name:KOSSUTH, LISA (MA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KOSSUTH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 REAR SOUTH MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OLD FORGE
Mailing Address - State:PA
Mailing Address - Zip Code:18518
Mailing Address - Country:US
Mailing Address - Phone:570-457-4747
Mailing Address - Fax:
Practice Address - Street 1:1201 S MAIN ST REAR
Practice Address - Street 2:
Practice Address - City:OLD FORGE
Practice Address - State:PA
Practice Address - Zip Code:18518-2365
Practice Address - Country:US
Practice Address - Phone:570-457-4747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-21
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA101YM0800X
PAPC010339101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health