Provider Demographics
NPI:1427544998
Name:ELLIOTT, STACY M
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:M
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MISSEY
Other - Middle Name:
Other - Last Name:ELLIOTT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:431 OLD COURSE DR
Mailing Address - Street 2:
Mailing Address - City:FRIENDSWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77546-5662
Mailing Address - Country:US
Mailing Address - Phone:409-443-8600
Mailing Address - Fax:
Practice Address - Street 1:1301 REGENTS PARK DR STE 103
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77058-2536
Practice Address - Country:US
Practice Address - Phone:281-282-1301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-07
Last Update Date:2018-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66496104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty