Provider Demographics
NPI:1801175294
Name:ELIAS, CEZANNE MAISEL (CLINICAL SOCIAL)
Entity type:Individual
Prefix:
First Name:CEZANNE
Middle Name:MAISEL
Last Name:ELIAS
Suffix:
Gender:F
Credentials:CLINICAL SOCIAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3660 ROME DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-4488
Mailing Address - Country:US
Mailing Address - Phone:765-446-9394
Mailing Address - Fax:765-447-8875
Practice Address - Street 1:3660 ROME DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4488
Practice Address - Country:US
Practice Address - Phone:765-446-9394
Practice Address - Fax:765-447-8875
Is Sole Proprietor?:No
Enumeration Date:2011-08-16
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35001672A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist