=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831218445
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELYSA RENEE SIEGELHEIM LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2007
-----------------------------------------------------
Last Update Date | 10/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1135 CLIFTON AVE STE 207
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07013-3643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-988-4241
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 49 ALMADERA DR
-----------------------------------------------------
City | WAYNE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07470-2471
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 551-404-2956
-----------------------------------------------------
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 | 37PC00348600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------