Provider Demographics
NPI:1518384023
Name:ELLIOTT, ANDREA (LCDC, SAP)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:LCDC, SAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 SIOUX ST
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-2445
Mailing Address - Country:US
Mailing Address - Phone:817-337-4518
Mailing Address - Fax:
Practice Address - Street 1:320 SIOUX ST
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-2445
Practice Address - Country:US
Practice Address - Phone:817-337-4518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-21
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10843101YA0400X
TX20370101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)