Provider Demographics
NPI:1902307317
Name:PANCHELLA, ALEXANDRA (LAC)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:PANCHELLA
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 PARK PL
Mailing Address - Street 2:
Mailing Address - City:AUDUBON
Mailing Address - State:NJ
Mailing Address - Zip Code:08106-1223
Mailing Address - Country:US
Mailing Address - Phone:856-264-1956
Mailing Address - Fax:
Practice Address - Street 1:105 EVESBORO MEDFORD RD STE M
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-3865
Practice Address - Country:US
Practice Address - Phone:609-353-5608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-22
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00398100103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling