Healthcare Provider Details

I. General information

NPI: 1689502890
Provider Name (Legal Business Name): ELISE STRADER
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 MANHATTAN DR APT D13
BOULDER CO
80303-4070
US

IV. Provider business mailing address

500 MANHATTAN DR APT D13
BOULDER CO
80303-4070
US

V. Phone/Fax

Practice location:
  • Phone: 310-433-0974
  • Fax:
Mailing address:
  • Phone: 310-433-0974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: