Provider Demographics
NPI:1104368075
Name:HEARD, ELAINA
Entity Type:Individual
Prefix:
First Name:ELAINA
Middle Name:
Last Name:HEARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3852 ISLAND WAY
Mailing Address - Street 2:
Mailing Address - City:ST. PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33705-6449
Mailing Address - Country:US
Mailing Address - Phone:269-277-2954
Mailing Address - Fax:
Practice Address - Street 1:8254 118TH AVENUE NORTH
Practice Address - Street 2:SUITE 100
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33773-5027
Practice Address - Country:US
Practice Address - Phone:727-541-5304
Practice Address - Fax:727-546-8527
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
FL1-19-35648103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst