Provider Demographics
NPI:1033126644
Name:ELLIOTT, BRYAN MITCHELL (LPC, LMFT)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:MITCHELL
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:LPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-5441
Mailing Address - Country:US
Mailing Address - Phone:325-949-3701
Mailing Address - Fax:325-947-3585
Practice Address - Street 1:2200 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-5441
Practice Address - Country:US
Practice Address - Phone:325-949-3701
Practice Address - Fax:325-947-3585
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14593101YP2500X
TX004794-041978106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3619LCOtherBLUE CROSS BLUE SHIELD