Provider Demographics
NPI:1376966572
Name:GOULBOURNE, ELISE ASHLEY (LLPC)
Entity Type:Individual
Prefix:MISS
First Name:ELISE
Middle Name:ASHLEY
Last Name:GOULBOURNE
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2995 E GRAND BLVD STE 1038
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3133
Mailing Address - Country:US
Mailing Address - Phone:313-758-0150
Mailing Address - Fax:313-758-0255
Practice Address - Street 1:2995 E GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3133
Practice Address - Country:US
Practice Address - Phone:313-758-0150
Practice Address - Fax:313-758-0255
Is Sole Proprietor?:No
Enumeration Date:2014-01-24
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015813103TC1900X
MI6451022680101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling