Provider Demographics
NPI:1982230611
Name:STUBBLEFIELD, ELYSSA
Entity type:Individual
Prefix:
First Name:ELYSSA
Middle Name:
Last Name:STUBBLEFIELD
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 1:965 N LIBERTY AVE
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84404-6247
Mailing Address - Country:US
Mailing Address - Phone:801-317-7837
Mailing Address - Fax:
Practice Address - Street 1:3590 HARRISON BLVD # GL2
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-2060
Practice Address - Country:US
Practice Address - Phone:801-317-7837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-13
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13621392-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical