Provider Demographics
NPI:1982825865
Name:ELLIOTT, MARY JANE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:JANE
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3779 VEST MILL RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-2991
Mailing Address - Country:US
Mailing Address - Phone:336-768-0919
Mailing Address - Fax:336-740-9135
Practice Address - Street 1:3779 VEST MILL RD
Practice Address - Street 2:SUITE B
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2991
Practice Address - Country:US
Practice Address - Phone:336-768-0919
Practice Address - Fax:336-740-9135
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18853103TC0700X
NC3939103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6001212Medicaid