Provider Demographics
NPI:1407975717
Name:ELLIOTT, WILLIAM JEROME (AMFT)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:JEROME
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11235 SUNBURST ST
Mailing Address - Street 2:
Mailing Address - City:LAKE VIEW TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:91342-6630
Mailing Address - Country:US
Mailing Address - Phone:818-335-8117
Mailing Address - Fax:
Practice Address - Street 1:760 MOUNTAIN VIEW ST
Practice Address - Street 2:
Practice Address - City:ALTADENA
Practice Address - State:CA
Practice Address - Zip Code:91001-4925
Practice Address - Country:US
Practice Address - Phone:626-798-6793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA122209106H00000X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist