Provider Demographics
NPI:1639131360
Name:ELTZ, MICHAEL J (PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:ELTZ
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 1:27 KNOWLES ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:RI
Mailing Address - Zip Code:02865-3301
Mailing Address - Country:US
Mailing Address - Phone:401-714-7440
Mailing Address - Fax:401-490-2619
Practice Address - Street 1:765 ALLENS AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-5443
Practice Address - Country:US
Practice Address - Phone:401-714-7440
Practice Address - Fax:401-490-2619
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-06
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
322D00000X
RIPS00748251S00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIME37214Medicaid