Provider Demographics
NPI:1154631091
Name:ETAPA, ELYSE NICOLE (PCC)
Entity Type:Individual
Prefix:
First Name:ELYSE
Middle Name:NICOLE
Last Name:ETAPA
Suffix:
Gender:F
Credentials:PCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7110 WHIPPLE AVE NW
Mailing Address - Street 2:SUITE C-106
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-7154
Mailing Address - Country:US
Mailing Address - Phone:330-703-6578
Mailing Address - Fax:330-703-6578
Practice Address - Street 1:7110 WHIPPLE AVE NW
Practice Address - Street 2:SUITE C-106
Practice Address - City:NORTH CANTON
Practice Address - State:OH
Practice Address - Zip Code:44720-7154
Practice Address - Country:US
Practice Address - Phone:330-703-6578
Practice Address - Fax:330-703-6578
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-13
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC0900340101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH57484Medicaid