Healthcare Provider Details

I. General information

NPI: 1417412263
Provider Name (Legal Business Name): ELYSE FINCHAM CDCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELYSE HAWOUT

II. Dates (important events)

Enumeration Date: 02/06/2019
Last Update Date: 12/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 HIGH ST NE
WARREN OH
44481-1222
US

IV. Provider business mailing address

527 N MERIDIAN RD
YOUNGSTOWN OH
44509-1227
US

V. Phone/Fax

Practice location:
  • Phone: 330-797-0070
  • Fax:
Mailing address:
  • Phone: 330-797-0070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.170898
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: