Provider Demographics
NPI:1518420603
Name:ELLIOTT, IMANI LYDIA
Entity Type:Individual
Prefix:MRS
First Name:IMANI
Middle Name:LYDIA
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7000 AUSTIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-4739
Mailing Address - Country:US
Mailing Address - Phone:718-762-7633
Mailing Address - Fax:718-888-8694
Practice Address - Street 1:7000 AUSTIN ST STE 200
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-4739
Practice Address - Country:US
Practice Address - Phone:718-762-7633
Practice Address - Fax:718-888-8694
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-07
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1518420603174400000X
252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty