Provider Demographics
NPI:1225327455
Name:D'ELISO, AUDRA (MS LPC)
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:
Last Name:D'ELISO
Suffix:
Gender:F
Credentials:MS LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2044 N RECKER RD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85215-2744
Mailing Address - Country:US
Mailing Address - Phone:480-788-2523
Mailing Address - Fax:
Practice Address - Street 1:2044 N RECKER RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85215-2744
Practice Address - Country:US
Practice Address - Phone:480-788-2523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-28
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-15734101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional