Provider Demographics
NPI:1720403033
Name:ELLIOT, KENDRA (MSED)
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:
Last Name:ELLIOT
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:472 VINEYARD AVE
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:NY
Mailing Address - Zip Code:12528-2320
Mailing Address - Country:US
Mailing Address - Phone:845-706-9582
Mailing Address - Fax:
Practice Address - Street 1:472 VINEYARD AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:NY
Practice Address - Zip Code:12528-2320
Practice Address - Country:US
Practice Address - Phone:845-706-9582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-24
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1792620174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist