=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710114095
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELISHIA L. PULLIAM MS, LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2009
-----------------------------------------------------
Last Update Date | 10/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1720 W FLORIST AVE STE 301
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53209-3800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-247-0801
-----------------------------------------------------
Fax | 414-247-0816
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 933 N MAYFAIR RD STE 101
-----------------------------------------------------
City | WAUWATOSA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53226-3432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-375-5444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 503-226
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------