Provider Demographics
NPI:1699011973
Name:ELLIOTT, RONTRELLA D
Entity Type:Individual
Prefix:
First Name:RONTRELLA
Middle Name:D
Last Name:ELLIOTT
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 1:331 CAMPBELL THICKETT RD
Mailing Address - Street 2:
Mailing Address - City:RIDGEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29472-6339
Mailing Address - Country:US
Mailing Address - Phone:843-821-3073
Mailing Address - Fax:843-851-8427
Practice Address - Street 1:331 CAMPBELL THICKETT RD
Practice Address - Street 2:
Practice Address - City:RIDGEVILLE
Practice Address - State:SC
Practice Address - Zip Code:29472-6339
Practice Address - Country:US
Practice Address - Phone:843-821-3073
Practice Address - Fax:843-851-8427
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-14
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10092104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker