Provider Demographics
NPI:1366061624
Name:ELYSIAN PSYCHOLOGY INC
Entity type:Organization
Organization Name:ELYSIAN PSYCHOLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:ISAACS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:773-412-7274
Mailing Address - Street 1:5315 N CLARK ST STE 166
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2290
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10250 CONSTELLATION BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067-6200
Practice Address - Country:US
Practice Address - Phone:312-388-8008
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-15
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1689987281OtherNATIONAL PLAN & PROVIDER ENUMERATION SYSTEM