Provider Demographics
NPI:1891384038
Name:ELITE EDUCATIONAL AND THERAPEUTIC SUPPORT SERVICES
Entity Type:Organization
Organization Name:ELITE EDUCATIONAL AND THERAPEUTIC SUPPORT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:SHILLABEER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:570-466-5870
Mailing Address - Street 1:155 COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:DURYEA
Mailing Address - State:PA
Mailing Address - Zip Code:18642-1403
Mailing Address - Country:US
Mailing Address - Phone:570-466-5870
Mailing Address - Fax:
Practice Address - Street 1:17946 CONTADOR DR
Practice Address - Street 2:
Practice Address - City:ROWLAND HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91748-4328
Practice Address - Country:US
Practice Address - Phone:570-466-5870
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALEP3615OtherEDUCATIONAL PSYCHOLOGY