Provider Demographics
NPI:1376363929
Name:FENELUS, ELISHA MARCELLA
Entity type:Individual
Prefix:
First Name:ELISHA
Middle Name:MARCELLA
Last Name:FENELUS
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 1:3980 W BROWARD BLVD APT 301
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-1081
Mailing Address - Country:US
Mailing Address - Phone:786-773-6505
Mailing Address - Fax:
Practice Address - Street 1:13195 SW 134TH ST STE 201
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4585
Practice Address - Country:US
Practice Address - Phone:786-655-9306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-16
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician