Provider Demographics
NPI:1780251983
Name:BEACH, ELYSE DELPHINE JOHNSON (MS, CF-SLP)
Entity type:Individual
Prefix:
First Name:ELYSE
Middle Name:DELPHINE JOHNSON
Last Name:BEACH
Suffix:
Gender:F
Credentials:MS, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6862 FOXTHORN RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-2677
Mailing Address - Country:US
Mailing Address - Phone:313-806-8082
Mailing Address - Fax:
Practice Address - Street 1:14153 RICK DR
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-2951
Practice Address - Country:US
Practice Address - Phone:586-566-0326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7151013455235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7151013455OtherSTATE OF MICHIGAN- DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS