Provider Demographics
NPI:1205569936
Name:SUTTLES, ELISHA (PLMHP)
Entity type:Individual
Prefix:
First Name:ELISHA
Middle Name:
Last Name:SUTTLES
Suffix:
Gender:F
Credentials:PLMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3127 MAPLEWOOD BLVD APT 28
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68134-5438
Mailing Address - Country:US
Mailing Address - Phone:402-594-8069
Mailing Address - Fax:
Practice Address - Street 1:6659 SORENSEN PKWY
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68152-2139
Practice Address - Country:US
Practice Address - Phone:402-502-9788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-09
Last Update Date:2022-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE12996101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health