Provider Demographics
NPI:1669032348
Name:EVELEIGH, ELISHA (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELISHA
Middle Name:
Last Name:EVELEIGH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4075 OLD WESTERN ROW RD
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-3104
Mailing Address - Country:US
Mailing Address - Phone:513-536-0267
Mailing Address - Fax:
Practice Address - Street 1:4075 OLD WESTERN ROW RD
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-3104
Practice Address - Country:US
Practice Address - Phone:513-536-0267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-16
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.009809103TC0700X
OHP.07977103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0384541Medicaid