Healthcare Provider Details

I. General information

NPI: 1710114095
Provider Name (Legal Business Name): ELISHIA L. PULLIAM MS, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2009
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 W FLORIST AVE STE 301
GLENDALE WI
53209-3800
US

IV. Provider business mailing address

933 N MAYFAIR RD STE 101
WAUWATOSA WI
53226-3432
US

V. Phone/Fax

Practice location:
  • Phone: 414-247-0801
  • Fax: 414-247-0816
Mailing address:
  • Phone: 414-375-5444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number503-226
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: