Provider Demographics
NPI:1093358962
Name:ANTROBUS, ELISE (LCSW)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:ANTROBUS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1772 CHASEWOOD PARK LN
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-4296
Mailing Address - Country:US
Mailing Address - Phone:404-402-2261
Mailing Address - Fax:
Practice Address - Street 1:707 WHITLOCK AVE SW STE C28
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-4655
Practice Address - Country:US
Practice Address - Phone:404-402-2261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000034341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical