Basic Information
| Provider Information | |||||||||
| NPI: | 1609499243 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAVINDIDZE | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | RANGANAI | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3444 BARN RD | ||||||||
| Address2: | |||||||||
| City: | APEX | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275027403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6107723734 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | WAKEMED HEALTH AND HOSPITALS | ||||||||
| Address2: | 3000 NEW BERN AVENUE | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193507722 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2020 | ||||||||
| LastUpdateDate: | 05/18/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | C010695 | NC | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.