Basic Information
| Provider Information | |||||||||
| NPI: | 1043761653 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRACK | ||||||||
| FirstName: | ELYSE | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 275 N EL CIELO RD | ||||||||
| Address2: | SUITE D408 | ||||||||
| City: | PALM SPRINGS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922626972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609695262 | ||||||||
| FaxNumber: | 7609695946 | ||||||||
| Practice Location | |||||||||
| Address1: | 275 N EL CIELO RD | ||||||||
| Address2: | SUITE D408 | ||||||||
| City: | PALM SPRINGS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922626972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609695262 | ||||||||
| FaxNumber: | 7609695946 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2016 | ||||||||
| LastUpdateDate: | 10/18/2016 | ||||||||
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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 | 65067 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 65067 | 01 | CA | LCSW | OTHER |