Provider Demographics
NPI:1316412091
Name:MAMMARELLO, ELIZABETH ANNE (LCSW)
Entity type:Individual
Prefix:MISS
First Name:ELIZABETH
Middle Name:ANNE
Last Name:MAMMARELLO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ANNE
Other - Last Name:WIDRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:671 EXCHANGE ST
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456-3498
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:671 EXCHANGE ST
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456-3498
Practice Address - Country:US
Practice Address - Phone:315-789-2613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0979021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical