Provider Demographics
NPI:1164515045
Name:ELLIOTT, SUZANNE HOLT (MA)
Entity Type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:HOLT
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 PIKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-2746
Mailing Address - Country:US
Mailing Address - Phone:304-252-0818
Mailing Address - Fax:
Practice Address - Street 1:136 SULLIVAN RD
Practice Address - Street 2:
Practice Address - City:GLEN MORGAN
Practice Address - State:WV
Practice Address - Zip Code:25813-7600
Practice Address - Country:US
Practice Address - Phone:304-256-4555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV567101YP2500X
WV21015103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0164229000Medicaid