Provider Demographics
NPI:1902228653
Name:ELLIOTT, AVEDON (LPC80053)
Entity Type:Individual
Prefix:MS
First Name:AVEDON
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:LPC80053
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5659 CECINA DR
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-2392
Mailing Address - Country:US
Mailing Address - Phone:239-478-1975
Mailing Address - Fax:
Practice Address - Street 1:3830 EVANS AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-9305
Practice Address - Country:US
Practice Address - Phone:239-939-2808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-15
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80053101YP2500X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional