Provider Demographics
NPI:1891879987
Name:ELLIOTT, MARK RICHARD (LCSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:RICHARD
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 SWEETBRIAR DR
Mailing Address - Street 2:
Mailing Address - City:GANSEVOORT
Mailing Address - State:NY
Mailing Address - Zip Code:12831-2526
Mailing Address - Country:US
Mailing Address - Phone:518-584-3600
Mailing Address - Fax:518-584-3747
Practice Address - Street 1:30 CRESCENT AVE
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-5142
Practice Address - Country:US
Practice Address - Phone:518-584-3600
Practice Address - Fax:518-584-3747
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR041228-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health