Provider Demographics
NPI:1942909486
Name:ELLER, EDWARD BLAKE
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:BLAKE
Last Name:ELLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4308 MERTON RD
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20853-2170
Mailing Address - Country:US
Mailing Address - Phone:240-543-6380
Mailing Address - Fax:
Practice Address - Street 1:1221 TAYLOR ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-5617
Practice Address - Country:US
Practice Address - Phone:240-543-6380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-23
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health