Provider Demographics
NPI:1285298182
Name:WAUGH, ELYSE (CDCA)
Entity type:Individual
Prefix:
First Name:ELYSE
Middle Name:
Last Name:WAUGH
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 WALLER ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-3561
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15221 STATE ROUTE 772
Practice Address - Street 2:
Practice Address - City:PIKETON
Practice Address - State:OH
Practice Address - Zip Code:45661-9062
Practice Address - Country:US
Practice Address - Phone:740-464-2269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-25
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1697000101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)