Basic Information
| Provider Information | |||||||||
| NPI: | 1891253373 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DALY | ||||||||
| FirstName: | ELSA | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PEER SPECIALIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 N MARKET BLVD STE C | ||||||||
| Address2: | |||||||||
| City: | CHEHALIS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985322677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3609480203 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 151 N MARKET BLVD STE C | ||||||||
| Address2: | |||||||||
| City: | CHEHALIS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985322677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3609480203 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2019 | ||||||||
| LastUpdateDate: | 06/23/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 06/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | 1891253373 | WA | N | 175T00000X | 1376696096 | WA | Y |
ID Information
| ID | Type | State | Issuer | Description | 1376696096 | 05 | WA | MEDICAID | 175T00000X | 05 | WA | MEDICAID |