=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588445464
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELISA PULLIAM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2023
-----------------------------------------------------
Last Update Date | 10/09/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 699 WOOLTOWN RD
-----------------------------------------------------
City | WERNERSVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19565-9515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-917-7137
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1001 MILLSTREAM DR
-----------------------------------------------------
City | MALVERN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19355-3127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-283-3268
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------