Provider Demographics
NPI:1740932607
Name:OUDEMANS-TILLEY, ELYSIA (MSW)
Entity type:Individual
Prefix:
First Name:ELYSIA
Middle Name:
Last Name:OUDEMANS-TILLEY
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:ELYSIA
Other - Middle Name:
Other - Last Name:OUDEMANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:PO BOX 6111
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042
Mailing Address - Country:US
Mailing Address - Phone:240-350-0026
Mailing Address - Fax:
Practice Address - Street 1:4702 WOODLAND ROAD
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-6331
Practice Address - Country:US
Practice Address - Phone:240-350-0026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-21
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040150851041C0700X
DCLC20000021101041C0700X
MD102991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical