Provider Demographics
NPI:1659625150
Name:SNIPES, ELYSE EDLER (MA)
Entity Type:Individual
Prefix:MRS
First Name:ELYSE
Middle Name:EDLER
Last Name:SNIPES
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7241
Mailing Address - Street 2:
Mailing Address - City:CAPO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92624-7241
Mailing Address - Country:US
Mailing Address - Phone:949-370-7103
Mailing Address - Fax:
Practice Address - Street 1:300 S EL CAMINO REAL
Practice Address - Street 2:SUITE 105
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-4069
Practice Address - Country:US
Practice Address - Phone:949-370-7103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-05
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51619106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist