Provider Demographics
NPI:1578365201
Name:NOONAN, ELISE MARIE
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:MARIE
Last Name:NOONAN
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 1:40 LANE AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-5410
Mailing Address - Country:US
Mailing Address - Phone:630-636-0730
Mailing Address - Fax:
Practice Address - Street 1:23800 NORTHWESTERN HWY STE 190L
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-7740
Practice Address - Country:US
Practice Address - Phone:734-440-9506
Practice Address - Fax:877-927-8461
Is Sole Proprietor?:No
Enumeration Date:2025-03-25
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician