Provider Demographics
NPI:1417009937
Name:ELLIOTT, STEPHEN SEALS (PHD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:SEALS
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 538622
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-8622
Mailing Address - Country:US
Mailing Address - Phone:910-742-9243
Mailing Address - Fax:888-746-1787
Practice Address - Street 1:3205 RANDALL PKWY STE 105
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-2565
Practice Address - Country:US
Practice Address - Phone:910-742-9243
Practice Address - Fax:888-746-1787
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1010103TC0700X, 103TC2200X
NC283106H00000X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP01126726OtherRR MEDICARE
NC6000042Medicaid
NCP01126726OtherRR MEDICARE
NC03553Medicare UPIN
NC2812618BMedicare PIN