Provider Demographics
NPI:1760711683
Name:SALK, ELLIOT DAVID (PHD)
Entity Type:Individual
Prefix:
First Name:ELLIOT
Middle Name:DAVID
Last Name:SALK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4757 E GREENWAY RD
Mailing Address - Street 2:#107-B, PMB 282
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-8513
Mailing Address - Country:US
Mailing Address - Phone:602-679-5481
Mailing Address - Fax:
Practice Address - Street 1:3509 E SHEA BLVD
Practice Address - Street 2:#117
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-3336
Practice Address - Country:US
Practice Address - Phone:602-569-0406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-24
Last Update Date:2009-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1176103T00000X
MI6301001675103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist