Provider Demographics
NPI:1922130376
Name:ELLIOTT, JUANITA SERENA (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:JUANITA
Middle Name:SERENA
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 141795
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99514-1795
Mailing Address - Country:US
Mailing Address - Phone:907-569-5033
Mailing Address - Fax:907-569-5033
Practice Address - Street 1:4034 REKA L5
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508
Practice Address - Country:US
Practice Address - Phone:907-569-5033
Practice Address - Fax:907-569-5033
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK278361171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCM5272Medicaid