Provider Demographics
NPI:1629585641
Name:CLEARENCE, ELYSIA MAE
Entity Type:Individual
Prefix:
First Name:ELYSIA
Middle Name:MAE
Last Name:CLEARENCE
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 1:92-1126 OLANI ST APT 1
Mailing Address - Street 2:
Mailing Address - City:KAPOLEI
Mailing Address - State:HI
Mailing Address - Zip Code:96707-4227
Mailing Address - Country:US
Mailing Address - Phone:714-210-9411
Mailing Address - Fax:
Practice Address - Street 1:92-1126 OLANI ST APT 1
Practice Address - Street 2:
Practice Address - City:KAPOLEI
Practice Address - State:HI
Practice Address - Zip Code:96707-4227
Practice Address - Country:US
Practice Address - Phone:714-210-9411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-29
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIBACB386532106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician