Provider Demographics
NPI:1073672937
Name:ELLIOTT, CHARLOTTE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:CHARLOTTE
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6334 CONSTITUTION DR STE 23
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1518
Mailing Address - Country:US
Mailing Address - Phone:260-209-1209
Mailing Address - Fax:260-782-3215
Practice Address - Street 1:6334 CONSTITUTION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1518
Practice Address - Country:US
Practice Address - Phone:260-209-1209
Practice Address - Fax:260-782-3215
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34004693A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200026750AMedicaid