Provider Demographics
NPI:1689202335
Name:CUSIMANO, ELISE NOELLE (NBC-HWC, RYT)
Entity type:Individual
Prefix:MISS
First Name:ELISE
Middle Name:NOELLE
Last Name:CUSIMANO
Suffix:
Gender:F
Credentials:NBC-HWC, RYT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 HILLTOP DR
Mailing Address - Street 2:
Mailing Address - City:WEATOGUE
Mailing Address - State:CT
Mailing Address - Zip Code:06089-9664
Mailing Address - Country:US
Mailing Address - Phone:716-450-3012
Mailing Address - Fax:
Practice Address - Street 1:2 TUNXIS RD STE 116
Practice Address - Street 2:
Practice Address - City:TARIFFVILLE
Practice Address - State:CT
Practice Address - Zip Code:06081-9687
Practice Address - Country:US
Practice Address - Phone:716-450-3012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-30
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174H00000X
CTA-3086754171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
No174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1811520810Medicaid