Provider Demographics
NPI:1942607346
Name:ELMORE, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ELMORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 E PARADISE LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-3201
Mailing Address - Country:US
Mailing Address - Phone:602-692-3015
Mailing Address - Fax:480-659-7230
Practice Address - Street 1:1320 E PARADISE LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-3201
Practice Address - Country:US
Practice Address - Phone:602-692-3015
Practice Address - Fax:480-659-7230
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-01
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ40431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ4043OtherSTATE LICENSE NUMBER