Provider Demographics
NPI:1164868048
Name:TERA, ELYSE (LAC DIPLAC)
Entity Type:Individual
Prefix:
First Name:ELYSE
Middle Name:
Last Name:TERA
Suffix:
Gender:F
Credentials:LAC DIPLAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 W 24TH ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-8368
Mailing Address - Country:US
Mailing Address - Phone:928-328-1975
Mailing Address - Fax:928-783-1975
Practice Address - Street 1:1150 W 24TH ST
Practice Address - Street 2:SUITE E
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-8368
Practice Address - Country:US
Practice Address - Phone:928-328-1975
Practice Address - Fax:928-783-1975
Is Sole Proprietor?:No
Enumeration Date:2013-05-17
Last Update Date:2013-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0587171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist