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NPI Code Detail

MEDICARE: MS. ELISE DEWALD

MEDICARE: MS. ELISE DEWALD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1106S00000XBehavior Technician
2106S00000XBehavior TechnicianRBT-19-106322

General Provider Information

NPI Number : 1518434190
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. ELISE DEWALD
Provider Business Mailing Address
First Line : 99 PASADENA AVE STE 10C
Second Line :
City : SOUTH PASADENA
State : CA
Zip : 91030-6142
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 99 PASADENA AVE STE 10C
Second Line :
City : SOUTH PASADENA
State : CA
Zip : 91030-6142
Country : US
Telephone Number : 616-502-3156
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/31/2018
Last Update Date : 12/08/2022

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