Provider Demographics
NPI:1598201600
Name:ELISE BERSHAW, LCSW-C
Entity Type:Organization
Organization Name:ELISE BERSHAW, LCSW-C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:ELISE
Authorized Official - Middle Name:WENDY
Authorized Official - Last Name:BERSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-C
Authorized Official - Phone:410-212-9463
Mailing Address - Street 1:PO BOX 67149
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215
Mailing Address - Country:US
Mailing Address - Phone:410-212-9463
Mailing Address - Fax:
Practice Address - Street 1:10 W MADISON ST
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-5239
Practice Address - Country:US
Practice Address - Phone:410-212-9463
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-12
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD12123101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1932331139OtherSOLO NPI