Healthcare Provider Details

I. General information

NPI: 1174003560
Provider Name (Legal Business Name): WALLIS ELYSE WELSH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2018
Last Update Date: 08/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 HANCOCK CT
QUINCY MA
02169-5210
US

IV. Provider business mailing address

50 WAVERLEY ST APT 2
BELMONT MA
02478-1960
US

V. Phone/Fax

Practice location:
  • Phone: 617-847-1950
  • Fax:
Mailing address:
  • Phone: 330-209-5728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number16-183
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: