Provider Demographics
NPI:1629259858
Name:MCCUTCHEON, ELISE DAWN (LMBT)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:DAWN
Last Name:MCCUTCHEON
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18605 RUFFNER DR UNIT 1E
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-9020
Mailing Address - Country:US
Mailing Address - Phone:858-337-2040
Mailing Address - Fax:
Practice Address - Street 1:18605 RUFFNER DR UNIT 1E
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-9020
Practice Address - Country:US
Practice Address - Phone:858-337-2040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-15
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
NC17820225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty