Basic Information
| Provider Information | |||||||||
| NPI: | 1467703850 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELSEY | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 E ROUTT AVE | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810042117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195438718 | ||||||||
| FaxNumber: | 7195435340 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 COLORADO AVE | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810042006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195438718 | ||||||||
| FaxNumber: | 7195435340 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2012 | ||||||||
| LastUpdateDate: | 08/28/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 1937 | CO | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 03022005 | 05 | CO | MEDICAID | 1937 | 01 | CO | COLO ST LIC | OTHER |