Provider Demographics
NPI:1952672966
Name:ELLIOTT, KATHLEEN (MA, MFT)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:384 SW UPPER TERRACE DR
Mailing Address - Street 2:#208
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1887
Mailing Address - Country:US
Mailing Address - Phone:541-633-5704
Mailing Address - Fax:
Practice Address - Street 1:384 SW UPPER TERRACE DR
Practice Address - Street 2:#208
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1887
Practice Address - Country:US
Practice Address - Phone:541-633-5704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-23
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36430101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health