Provider Demographics
NPI:1558114330
Name:MYERS, ELLIOTT (PPS)
Entity Type:Individual
Prefix:
First Name:ELLIOTT
Middle Name:
Last Name:MYERS
Suffix:
Gender:M
Credentials:PPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 W LUGONIA AVE
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-2234
Mailing Address - Country:US
Mailing Address - Phone:909-307-2460
Mailing Address - Fax:
Practice Address - Street 1:20 W LUGONIA AVE
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-2234
Practice Address - Country:US
Practice Address - Phone:909-307-2460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-10
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA230155827101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool