Provider Demographics
NPI:1497573901
Name:ELLIOTT, ERIC
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:ELLIOTT
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 1:2933 BAY VILLAGE CIR APT 2006
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-2295
Mailing Address - Country:US
Mailing Address - Phone:415-307-5259
Mailing Address - Fax:
Practice Address - Street 1:2933 BAY VILLAGE CIR APT 2006
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2295
Practice Address - Country:US
Practice Address - Phone:415-307-5259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool