Provider Demographics
NPI:1265205306
Name:ELBASTAWISY, NANCY
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:ELBASTAWISY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:632 PONDSIDE LN
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-9479
Mailing Address - Country:US
Mailing Address - Phone:646-510-6076
Mailing Address - Fax:
Practice Address - Street 1:125 SCHNEIDER DR UNIT B
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17046-4875
Practice Address - Country:US
Practice Address - Phone:717-270-2425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-31
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH006767103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst