Healthcare Provider Details

I. General information

NPI: 1538779749
Provider Name (Legal Business Name): ELISA PANCHYSHYN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2020
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1711 COUNTY ROAD B W STE 200S
ROSEVILLE MN
55113-4068
US

IV. Provider business mailing address

6221 CLINTON AVE
RICHFIELD MN
55423-1649
US

V. Phone/Fax

Practice location:
  • Phone: 651-486-4828
  • Fax:
Mailing address:
  • Phone: 952-491-3196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: