Provider Demographics
NPI:1093890139
Name:ELLIOTT, LISA M (PHD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 99213
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0213
Mailing Address - Country:US
Mailing Address - Phone:682-885-4871
Mailing Address - Fax:682-885-3939
Practice Address - Street 1:3201 TEASLEY LN
Practice Address - Street 2:STE 202
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76210-8302
Practice Address - Country:US
Practice Address - Phone:940-484-4311
Practice Address - Fax:940-484-5075
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25244103G00000X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1891765178OtherCCMC NPI NUMBER
TX9079951OtherPHCS PIN
TX10012429OtherAMERIGROUP PIN
TX165130901Medicaid
TX112230100OtherFIRSTCAR PIN
TX124135OtherSUPERIOR PIN
TX00G981OtherBCBSTX GRP PIN
TX82152POtherBCBSTX IND PIN
TX849402OtherFIRSTHEALTH PIN