Basic Information
| Provider Information | |||||||||
| NPI: | 1093090359 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADFORD | ||||||||
| FirstName: | ELYSE | ||||||||
| MiddleName: | WISEMAN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 RENAISSANCE CTR | ||||||||
| Address2: | SUITE 2600 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482431502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8558326727 | ||||||||
| FaxNumber: | 7726759100 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 RENAISSANCE CTR | ||||||||
| Address2: | SUITE 2600 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482431502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8558326727 | ||||||||
| FaxNumber: | 7726759100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2011 | ||||||||
| LastUpdateDate: | 01/07/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 6301014952 | MI | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 103K00000X | 1118442 | MI | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.