Provider Demographics
NPI:1548575004
Name:BURRELL, ELISE (NCTMB, LMP)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:BURRELL
Suffix:
Gender:F
Credentials:NCTMB, LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3907 78TH AVENUE CT W
Mailing Address - Street 2:#D104
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-3264
Mailing Address - Country:US
Mailing Address - Phone:253-241-5034
Mailing Address - Fax:
Practice Address - Street 1:4441 PARADISE AVE W
Practice Address - Street 2:BASEMENT
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-1023
Practice Address - Country:US
Practice Address - Phone:253-241-5034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-09
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60156491225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist