Provider Demographics
NPI:1538859400
Name:CLERKIN, ELISE
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:CLERKIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 SEMINOLE TRL UNIT 6175
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-1006
Mailing Address - Country:US
Mailing Address - Phone:434-207-2242
Mailing Address - Fax:
Practice Address - Street 1:1600 PEPPERIDGE LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-7502
Practice Address - Country:US
Practice Address - Phone:434-207-2242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-12
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6982103TC0700X
VA0810007724103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical