Provider Demographics
NPI:1558007047
Name:ELYASSAKI, ITEN
Entity Type:Individual
Prefix:
First Name:ITEN
Middle Name:
Last Name:ELYASSAKI
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 1:95 KENTUCKY DR UNIT 303
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:KY
Mailing Address - Zip Code:41071-1100
Mailing Address - Country:US
Mailing Address - Phone:513-377-1041
Mailing Address - Fax:
Practice Address - Street 1:9415 MONTGOMERY RD STE G
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:OH
Practice Address - Zip Code:45242-7641
Practice Address - Country:US
Practice Address - Phone:513-377-1041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1902230101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health