Provider Demographics
NPI:1467644781
Name:ELLIOTT, TRESA L (PH D)
Entity Type:Individual
Prefix:
First Name:TRESA
Middle Name:L
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 WESLIN COVE DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35757-8704
Mailing Address - Country:US
Mailing Address - Phone:256-503-0856
Mailing Address - Fax:
Practice Address - Street 1:130 WESLIN COVE DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35757-8704
Practice Address - Country:US
Practice Address - Phone:256-503-0856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-10
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1443103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical