Provider Demographics
NPI:1356114102
Name:GLINES, ELISE
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:GLINES
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 1:321 VALENCIA STREET
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32561
Mailing Address - Country:US
Mailing Address - Phone:310-913-2652
Mailing Address - Fax:
Practice Address - Street 1:321 VALENCIA ST
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-4031
Practice Address - Country:US
Practice Address - Phone:310-913-2652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-02
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAGC001641170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS