Provider Demographics
NPI:1518956648
Name:ELLIOTT, GARY W (PHD)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:W
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 1:314 W CATALPA
Mailing Address - Street 2:SUITE E
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545
Mailing Address - Country:US
Mailing Address - Phone:574-254-1700
Mailing Address - Fax:574-254-2930
Practice Address - Street 1:314 W CATALPA
Practice Address - Street 2:SUITE E
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545
Practice Address - Country:US
Practice Address - Phone:574-254-1700
Practice Address - Fax:574-254-2930
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20010470A103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1844001OtherOAKLAWN PSYCHIATRIC CENTE
IN203300AMedicare ID - Type Unspecified