Provider Demographics
NPI:1194009035
Name:DAXE, ELISE D
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:D
Last Name:DAXE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELISE
Other - Middle Name:D
Other - Last Name:DAXE-PULLINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW, LCAC
Mailing Address - Street 1:601 WALL ST
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-2512
Mailing Address - Country:US
Mailing Address - Phone:219-531-3500
Mailing Address - Fax:
Practice Address - Street 1:3176 LANCER ST
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-4408
Practice Address - Country:US
Practice Address - Phone:219-762-9557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-10
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34006342A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical