Provider Demographics
NPI:1528410149
Name:MARRIOTT, ELLE
Entity Type:Individual
Prefix:
First Name:ELLE
Middle Name:
Last Name:MARRIOTT
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 1:3725 BELFORT RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-5813
Mailing Address - Country:US
Mailing Address - Phone:904-296-1055
Mailing Address - Fax:
Practice Address - Street 1:3725 BELFORT RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-5813
Practice Address - Country:US
Practice Address - Phone:904-296-1055
Practice Address - Fax:904-448-7700
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-07
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 13582101YM0800X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDMedicaid