Provider Demographics
NPI:1821782376
Name:RAUPP-GARDNER, ELYSE MAREA (LPCA)
Entity Type:Individual
Prefix:
First Name:ELYSE
Middle Name:MAREA
Last Name:RAUPP-GARDNER
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 FLORIDA RD
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-6540
Mailing Address - Country:US
Mailing Address - Phone:502-751-9850
Mailing Address - Fax:
Practice Address - Street 1:2355 STATE ST
Practice Address - Street 2:ST 101
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-6540
Practice Address - Country:US
Practice Address - Phone:503-270-3072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-07
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPCC.0020582101YM0800X
ORR8511101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health