Provider Demographics
NPI:1881028694
Name:ELLIOTT, REN AVERY (LPC)
Entity Type:Individual
Prefix:
First Name:REN
Middle Name:AVERY
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:E
Other - Last Name:WOODALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:PO BOX 2526
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-2526
Mailing Address - Country:US
Mailing Address - Phone:417-347-7600
Mailing Address - Fax:
Practice Address - Street 1:305 S VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64801-2323
Practice Address - Country:US
Practice Address - Phone:417-347-7730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
MO2017030629101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490078228Medicaid