Provider Demographics
NPI:1063224830
Name:ENDELEA ELEVATE
Entity type:Organization
Organization Name:ENDELEA ELEVATE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DOMINIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-615-9211
Mailing Address - Street 1:660 S BAGDAD RD STE 420
Mailing Address - Street 2:
Mailing Address - City:LEANDER
Mailing Address - State:TX
Mailing Address - Zip Code:78641-5049
Mailing Address - Country:US
Mailing Address - Phone:502-615-9211
Mailing Address - Fax:
Practice Address - Street 1:1939 GOLDSMITH LN STE 214
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-3178
Practice Address - Country:US
Practice Address - Phone:502-414-4380
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ENDELEA ELEVATE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-01-20
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty