Provider Demographics
NPI:1083712186
Name:ELLIOTT, CHARLES HAROLD (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:HAROLD
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:CHARLES
Other - Middle Name:H
Other - Last Name:ELLIOTT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1 SAN RAFAEL AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-1116
Mailing Address - Country:US
Mailing Address - Phone:505-823-1600
Mailing Address - Fax:505-823-1611
Practice Address - Street 1:1 SAN RAFAEL AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87122-1116
Practice Address - Country:US
Practice Address - Phone:505-823-1600
Practice Address - Fax:505-823-1611
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2013-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM333103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical