Provider Demographics
NPI:1235769852
Name:ELLIOTT, THERESA LAVERNE
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:LAVERNE
Last Name:ELLIOTT
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 1:2292 WESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20601-3905
Mailing Address - Country:US
Mailing Address - Phone:202-425-7616
Mailing Address - Fax:
Practice Address - Street 1:2292 WESTWOOD DR
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20601-3905
Practice Address - Country:US
Practice Address - Phone:202-425-7616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-23
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant