Provider Demographics
NPI:1699224048
Name:ELAM, LISA GAYE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:GAYE
Last Name:ELAM
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 1:121 PORTSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:CAPE CANAVERAL
Mailing Address - State:FL
Mailing Address - Zip Code:32920-3464
Mailing Address - Country:US
Mailing Address - Phone:443-373-7056
Mailing Address - Fax:
Practice Address - Street 1:1430 PALM ST
Practice Address - Street 2:
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19604-1855
Practice Address - Country:US
Practice Address - Phone:443-373-7056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-27
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC0958101YP2500X
PAPC009157101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional