Provider Demographics
NPI:1972955615
Name:ANDERSON, ELYSSA MARIE (MFT-I, CPC-I, CADC-I)
Entity Type:Individual
Prefix:
First Name:ELYSSA
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MFT-I, CPC-I, CADC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4221 MCLEOD DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-5215
Mailing Address - Country:US
Mailing Address - Phone:702-474-6450
Mailing Address - Fax:
Practice Address - Street 1:4221 MCLEOD DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-5215
Practice Address - Country:US
Practice Address - Phone:702-474-6450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-06
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV07180-LCI101YA0400X
NVMI4221106H00000X
NVC15112101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVPENDINGOtherCADC-I
NVPENDINGOtherMFT-I