Provider Demographics
NPI:1750004842
Name:KISIVULI, ELIJAH
Entity type:Individual
Prefix:
First Name:ELIJAH
Middle Name:
Last Name:KISIVULI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 MOUNT VERNON ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01854-3313
Mailing Address - Country:US
Mailing Address - Phone:978-427-8410
Mailing Address - Fax:
Practice Address - Street 1:21 GEORGE ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-2228
Practice Address - Country:US
Practice Address - Phone:978-453-5736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-22
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor