Provider Demographics
NPI:1245892405
Name:PARKE, ELYSE MARTINA (PHD)
Entity type:Individual
Prefix:DR
First Name:ELYSE
Middle Name:MARTINA
Last Name:PARKE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 RICHMOND AVE APT 243
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77006-5578
Mailing Address - Country:US
Mailing Address - Phone:702-324-3357
Mailing Address - Fax:
Practice Address - Street 1:6 TAMPA GENERAL CIR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-3571
Practice Address - Country:US
Practice Address - Phone:813-844-3541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-08
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10491103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist