Provider Demographics
NPI:1073811139
Name:ELLIOTT, CYNTHIA J (LCSW)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:J
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:J
Other - Last Name:MOSES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1910 GREENWOOD DR STE D
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-2430
Mailing Address - Country:US
Mailing Address - Phone:573-785-5224
Mailing Address - Fax:
Practice Address - Street 1:1910 GREENWOOD DR STE D
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-2430
Practice Address - Country:US
Practice Address - Phone:573-785-5224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-14
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2589-C1041C0700X
MO20070256531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1073811139Medicaid