Provider Demographics
NPI:1548804594
Name:RAY, ELYSIA MARIE
Entity type:Individual
Prefix:
First Name:ELYSIA
Middle Name:MARIE
Last Name:RAY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2990 N PERRYVILLE RD UNIT 1100
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-6827
Mailing Address - Country:US
Mailing Address - Phone:815-469-1500
Mailing Address - Fax:779-216-3069
Practice Address - Street 1:2990 N PERRYVILLE RD UNIT 1100
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-6827
Practice Address - Country:US
Practice Address - Phone:815-469-1500
Practice Address - Fax:779-216-3069
Is Sole Proprietor?:No
Enumeration Date:2019-11-02
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician