1053284596 NPI number — ELIZABETH LACEY ROBERTS PSYCH CRNP

Table of content: ELIZABETH LACEY ROBERTS PSYCH CRNP (NPI 1053284596)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053284596 NPI number — ELIZABETH LACEY ROBERTS PSYCH CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBERTS
Provider First Name:
ELIZABETH
Provider Middle Name:
LACEY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PSYCH CRNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROBERTS
Provider Other First Name:
ELIZABETH
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PSYCH CRNP
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1053284596
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/29/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
429 MARTY LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOWANDA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18848-7897
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-250-7837
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
429 MARTY LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOWANDA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18848-7897
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-250-7837
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/29/2025

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  SP033921 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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