Provider Demographics
NPI:1265696801
Name:MECKBACH, ELISE KATHRYN (LPC)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:KATHRYN
Last Name:MECKBACH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:ELISE
Other - Middle Name:KATHRYN
Other - Last Name:BETTOZZI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7 DOCK HILL RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17842-8910
Mailing Address - Country:US
Mailing Address - Phone:570-837-2123
Mailing Address - Fax:570-837-2185
Practice Address - Street 1:1205 RIVER AVE FL 2
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-3724
Practice Address - Country:US
Practice Address - Phone:570-326-4118
Practice Address - Fax:570-326-5533
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-14
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC005997101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1035098140001Medicaid