Provider Demographics
NPI:1639808942
Name:ILSENG, EMILY RAE
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:RAE
Last Name:ILSENG
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 1:18811 MOUNTAIN SHADE DR
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77388-5169
Mailing Address - Country:US
Mailing Address - Phone:979-824-6160
Mailing Address - Fax:
Practice Address - Street 1:531 SHELF ROCK
Practice Address - Street 2:
Practice Address - City:DRIFTWOOD
Practice Address - State:TX
Practice Address - Zip Code:78619-4387
Practice Address - Country:US
Practice Address - Phone:979-824-6160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX204591106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist