Provider Demographics
NPI:1679694186
Name:ELLIOTT, SUSAN AUGUSTE (LPMA)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:AUGUSTE
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:LPMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 HEMLOCK RD
Mailing Address - Street 2:
Mailing Address - City:EAST CALAIS
Mailing Address - State:VT
Mailing Address - Zip Code:05650-8169
Mailing Address - Country:US
Mailing Address - Phone:802-456-1600
Mailing Address - Fax:
Practice Address - Street 1:53 HEMLOCK ROAD
Practice Address - Street 2:
Practice Address - City:EAST CALAIS
Practice Address - State:VT
Practice Address - Zip Code:05650
Practice Address - Country:US
Practice Address - Phone:802-456-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT047-0000515103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1003431Medicaid