Provider Demographics
NPI:1598593568
Name:VINCENT, ELYSE (LPC, MC)
Entity type:Individual
Prefix:
First Name:ELYSE
Middle Name:
Last Name:VINCENT
Suffix:
Gender:F
Credentials:LPC, MC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14114 W CHARTER OAK RD
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85379-5512
Mailing Address - Country:US
Mailing Address - Phone:623-236-6978
Mailing Address - Fax:
Practice Address - Street 1:4646 E GREENWAY RD STE 100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-4805
Practice Address - Country:US
Practice Address - Phone:679-294-9981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-22
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
AZLPC-22844101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health