Provider Demographics
NPI:1336611623
Name:ELLIOTT, AMANDA CAROLINE (LSAA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:CAROLINE
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:LSAA
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 1477
Mailing Address - Street 2:
Mailing Address - City:BAYARD
Mailing Address - State:NM
Mailing Address - Zip Code:88023-1477
Mailing Address - Country:US
Mailing Address - Phone:575-654-5568
Mailing Address - Fax:
Practice Address - Street 1:214 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-5353
Practice Address - Country:US
Practice Address - Phone:575-654-5568
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-26
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCSA0201351101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)