Basic Information
| Provider Information | |||||||||
| NPI: | 1194258574 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BIRDSONG | ||||||||
| FirstName: | ELISE | ||||||||
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| Credential: | CDPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2610 WETMORE AVE | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982012927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252585270 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2610 WETMORE AVE | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982012927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252585270 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2017 | ||||||||
| LastUpdateDate: | 04/10/2017 | ||||||||
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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 | 101YA0400X | WA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 60736213 | 01 | CDPT CERTIFICATION | OTHER |