Provider Demographics
NPI:1003320789
Name:ELMORE, AMIE (LBA)
Entity Type:Individual
Prefix:
First Name:AMIE
Middle Name:
Last Name:ELMORE
Suffix:
Gender:F
Credentials:LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22902-5374
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1006 E MARKET ST STE C
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22902-5374
Practice Address - Country:US
Practice Address - Phone:804-836-8541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-17
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133000809103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst