Provider Demographics
NPI:1295472496
Name:ELYSEE, LIANA GLORIA
Entity type:Individual
Prefix:
First Name:LIANA
Middle Name:GLORIA
Last Name:ELYSEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SACRAMENTO DR APT 65
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-1677
Mailing Address - Country:US
Mailing Address - Phone:540-497-3245
Mailing Address - Fax:
Practice Address - Street 1:5604A VIRGINIA BEACH BLVD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-5681
Practice Address - Country:US
Practice Address - Phone:757-455-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-18
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2204000911235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist