Provider Demographics
NPI:1164930582
Name:BESSON, ELISSA RAE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:RAE
Last Name:BESSON
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2378 WOODLAKE DR STE 280
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-6016
Mailing Address - Country:US
Mailing Address - Phone:517-706-0421
Mailing Address - Fax:
Practice Address - Street 1:2378 WOODLAKE DR STE 280
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-6016
Practice Address - Country:US
Practice Address - Phone:517-706-0421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-19
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101005384235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist