Provider Demographics
NPI:1114294568
Name:ISOM, ELLIOT (LPC)
Entity Type:Individual
Prefix:DR
First Name:ELLIOT
Middle Name:
Last Name:ISOM
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2013 E 21ST ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:HAYS
Mailing Address - State:KS
Mailing Address - Zip Code:67601-2738
Mailing Address - Country:US
Mailing Address - Phone:785-639-5135
Mailing Address - Fax:
Practice Address - Street 1:1301 OAK ST
Practice Address - Street 2:
Practice Address - City:HAYS
Practice Address - State:KS
Practice Address - Zip Code:67601-3659
Practice Address - Country:US
Practice Address - Phone:785-628-3575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-29
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
KS3576101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR174662526Medicaid