Provider Demographics
NPI:1053821058
Name:BHAGWAT, ELISE ALEXANDER I
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:ALEXANDER
Last Name:BHAGWAT
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8609 2ND AVE STE 506B
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-3362
Mailing Address - Country:US
Mailing Address - Phone:240-398-3514
Mailing Address - Fax:877-637-7490
Practice Address - Street 1:8609 2ND AVE STE 506B
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-3362
Practice Address - Country:US
Practice Address - Phone:240-398-3514
Practice Address - Fax:877-637-7490
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-04
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD2306101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional