Provider Demographics
NPI:1548725435
Name:ELLIOTT, LACRESIA (LSW)
Entity type:Individual
Prefix:
First Name:LACRESIA
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 W TOWNSHIP LINE RD STE 4
Mailing Address - Street 2:
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083-5237
Mailing Address - Country:US
Mailing Address - Phone:215-219-6263
Mailing Address - Fax:
Practice Address - Street 1:410 W TOWNSHIP LINE RD STE 4
Practice Address - Street 2:
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-5237
Practice Address - Country:US
Practice Address - Phone:215-219-6263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW128509104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PASW128509Medicaid