Provider Demographics
NPI:1184448029
Name:FISHKIN, ELYSE GUSTIN (MED)
Entity type:Individual
Prefix:
First Name:ELYSE
Middle Name:GUSTIN
Last Name:FISHKIN
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 BEECHWOOD RD
Mailing Address - Street 2:
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02482-2319
Mailing Address - Country:US
Mailing Address - Phone:781-235-4864
Mailing Address - Fax:
Practice Address - Street 1:67 BEECHWOOD RD
Practice Address - Street 2:
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02482-2319
Practice Address - Country:US
Practice Address - Phone:781-235-4864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-07
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA588235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist