Provider Demographics
NPI:1366831489
Name:ELLIOTT, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
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 1:1735 HECKLE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-1885
Mailing Address - Country:US
Mailing Address - Phone:704-299-1814
Mailing Address - Fax:
Practice Address - Street 1:2505 BULLFROG LN.
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720
Practice Address - Country:US
Practice Address - Phone:704-299-1814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-13
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10712104100000X
NCC0108561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1831114735Medicaid