Provider Demographics
NPI:1508164294
Name:MEDIANICK, ANN ELIZABETH (M A, M S)
Entity Type:Individual
Prefix:MRS
First Name:ANN
Middle Name:ELIZABETH
Last Name:MEDIANICK
Suffix:
Gender:F
Credentials:M A, M S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEOLA
Mailing Address - State:PA
Mailing Address - Zip Code:17540-1753
Mailing Address - Country:US
Mailing Address - Phone:717-556-0149
Mailing Address - Fax:717-556-0149
Practice Address - Street 1:219 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEOLA
Practice Address - State:PA
Practice Address - Zip Code:17540-1753
Practice Address - Country:US
Practice Address - Phone:717-556-0149
Practice Address - Fax:717-556-0149
Is Sole Proprietor?:No
Enumeration Date:2011-03-04
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC005775101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional