Provider Demographics
NPI:1750690640
Name:FORDYCE, ELISA LYNN (PLMHP)
Entity type:Individual
Prefix:MS
First Name:ELISA
Middle Name:LYNN
Last Name:FORDYCE
Suffix:
Gender:F
Credentials:PLMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17851 MARGO ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68136-2093
Mailing Address - Country:US
Mailing Address - Phone:402-990-5796
Mailing Address - Fax:
Practice Address - Street 1:5115 F ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68117-2807
Practice Address - Country:US
Practice Address - Phone:402-397-9866
Practice Address - Fax:402-397-1404
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-27
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE9164101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE470765107Medicaid