Provider Demographics
NPI:1659438554
Name:ELIAS, SANDRA L (PHD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
Last Name:ELIAS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 BERGER AVE
Mailing Address - Street 2:
Mailing Address - City:OAKHURST
Mailing Address - State:NJ
Mailing Address - Zip Code:07755-1724
Mailing Address - Country:US
Mailing Address - Phone:732-660-0203
Mailing Address - Fax:732-660-0781
Practice Address - Street 1:403 BERGER AVE
Practice Address - Street 2:
Practice Address - City:OAKHURST
Practice Address - State:NJ
Practice Address - Zip Code:07755-1724
Practice Address - Country:US
Practice Address - Phone:732-660-0203
Practice Address - Fax:732-660-0781
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35S100324200103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ35S100324200OtherPSYCHOLOGIST LICENSE