Provider Demographics
NPI:1033658901
Name:BENNETT, ELISE WALSH (LAC)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:WALSH
Last Name:BENNETT
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:VT
Mailing Address - Zip Code:05060-1363
Mailing Address - Country:US
Mailing Address - Phone:802-728-9600
Mailing Address - Fax:
Practice Address - Street 1:43 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:VT
Practice Address - Zip Code:05060-1363
Practice Address - Country:US
Practice Address - Phone:802-728-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT091.0126650171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist