Provider Demographics
NPI:1740214766
Name:ELMORE, RICHARD T JR (PHD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:T
Last Name:ELMORE
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:100 RIALTO PL
Mailing Address - Street 2:SUITE 754
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3055
Mailing Address - Country:US
Mailing Address - Phone:321-728-9620
Mailing Address - Fax:321-951-1928
Practice Address - Street 1:100 RIALTO PL
Practice Address - Street 2:SUITE 754
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3055
Practice Address - Country:US
Practice Address - Phone:321-728-9620
Practice Address - Fax:321-951-1928
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY3228103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75204OtherBCBS PROVIDER NUMBER
FL592345361OtherTRICARE PROVIDER #
FL75204OtherBCBS PROVIDER NUMBER