Provider Demographics
NPI:1720759343
Name:HARRISON, ELISE (BCBA)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:HARRISON
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 ALBEMARLE AVE SE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24013-2327
Mailing Address - Country:US
Mailing Address - Phone:276-920-4547
Mailing Address - Fax:
Practice Address - Street 1:312 WHITWELL DR
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24019-2039
Practice Address - Country:US
Practice Address - Phone:540-366-7399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133001985103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0133001985OtherVIRGINIA BOARD OF MEDICINE