Provider Demographics
NPI:1497138903
Name:DONAHUE, ELISE CAROLYN TISDALE
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:CAROLYN TISDALE
Last Name:DONAHUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELISE
Other - Middle Name:CAROLYN
Other - Last Name:TISDALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5860 KAPPA ST
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-2823
Mailing Address - Country:US
Mailing Address - Phone:619-855-4900
Mailing Address - Fax:
Practice Address - Street 1:5860 KAPPA ST
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-2823
Practice Address - Country:US
Practice Address - Phone:619-855-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-01
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-16-24238103K00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health