Provider Demographics
NPI:1275263824
Name:DANIEL, ELISSA KATHERINE
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:KATHERINE
Last Name:DANIEL
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 1:4033 W RAWSON AVE
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-9434
Mailing Address - Country:US
Mailing Address - Phone:414-795-7731
Mailing Address - Fax:
Practice Address - Street 1:10045 W LISBON AVE
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-2446
Practice Address - Country:US
Practice Address - Phone:414-358-7144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-15
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health