Provider Demographics
NPI:1528627148
Name:HENSON, ELYSE B (RD)
Entity type:Individual
Prefix:
First Name:ELYSE
Middle Name:B
Last Name:HENSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:ELYSE
Other - Middle Name:H
Other - Last Name:MORRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:2115 KRAMER LN STE 100
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-4013
Mailing Address - Country:US
Mailing Address - Phone:512-978-9901
Mailing Address - Fax:
Practice Address - Street 1:2901 MONTOPOLIS DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78741-6411
Practice Address - Country:US
Practice Address - Phone:512-978-9901
Practice Address - Fax:512-901-9765
Is Sole Proprietor?:No
Enumeration Date:2019-06-07
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX81697133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered