Provider Demographics
NPI:1275124786
Name:ELISANO, ELYSE MARIE
Entity Type:Individual
Prefix:MS
First Name:ELYSE MARIE
Middle Name:
Last Name:ELISANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 WILLOW DR
Mailing Address - Street 2:
Mailing Address - City:OLD TAPPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-6833
Mailing Address - Country:US
Mailing Address - Phone:551-579-9210
Mailing Address - Fax:
Practice Address - Street 1:180 OLD TAPPAN RD BLDG 32ND
Practice Address - Street 2:
Practice Address - City:OLD TAPPAN
Practice Address - State:NJ
Practice Address - Zip Code:07675-7052
Practice Address - Country:US
Practice Address - Phone:201-995-1004
Practice Address - Fax:201-345-7121
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-27
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL05994800104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker