Provider Demographics
NPI:1497015812
Name:BLACK, ELYSSA MARGARET (LSW)
Entity type:Individual
Prefix:MS
First Name:ELYSSA
Middle Name:MARGARET
Last Name:BLACK
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3395 PLYMOUTH ROAD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-3765
Mailing Address - Country:US
Mailing Address - Phone:952-939-0396
Mailing Address - Fax:952-939-9266
Practice Address - Street 1:3395 PLYMOUTH ROAD
Practice Address - Street 2:ST. DAVID'S CENTER
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-3765
Practice Address - Country:US
Practice Address - Phone:952-939-0396
Practice Address - Fax:952-939-9266
Is Sole Proprietor?:No
Enumeration Date:2012-05-18
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN21294-LSW104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker