Provider Demographics
NPI:1629894589
Name:DAMILATIS, ELISE (LCSWA, LCASA)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:DAMILATIS
Suffix:
Gender:F
Credentials:LCSWA, LCASA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1076 BEAR CREEK RD
Mailing Address - Street 2:
Mailing Address - City:LEICESTER
Mailing Address - State:NC
Mailing Address - Zip Code:28748-6312
Mailing Address - Country:US
Mailing Address - Phone:631-682-8883
Mailing Address - Fax:
Practice Address - Street 1:1076 BEAR CREEK RD
Practice Address - Street 2:
Practice Address - City:LEICESTER
Practice Address - State:NC
Practice Address - Zip Code:28748-6312
Practice Address - Country:US
Practice Address - Phone:631-682-8883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC29963101YA0400X
NCP021077104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)