Provider Demographics
NPI:1760033401
Name:PROBASCO, ELISE M (QMHS BA CMS BA)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:M
Last Name:PROBASCO
Suffix:
Gender:F
Credentials:QMHS BA CMS BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:434 EASTLAND RD
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:OH
Mailing Address - Zip Code:44017-1217
Mailing Address - Country:US
Mailing Address - Phone:440-234-2006
Mailing Address - Fax:
Practice Address - Street 1:111 S BROAD ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-4398
Practice Address - Country:US
Practice Address - Phone:440-260-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-24
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X
OH251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management