Provider Demographics
NPI:1952952913
Name:EZELLE, ELISE DOBSON (LICSW)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:DOBSON
Last Name:EZELLE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2617 7TH ST
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35401-1803
Mailing Address - Country:US
Mailing Address - Phone:205-860-5113
Mailing Address - Fax:205-882-5836
Practice Address - Street 1:2617 7TH ST
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-1803
Practice Address - Country:US
Practice Address - Phone:205-860-5113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-21
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5021C1041C0700X
AL3639G104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical