Provider Demographics
NPI:1750798914
Name:ELLIOTT, ALICIA (MS)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 LAKELAND RD
Mailing Address - Street 2:
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-3836
Mailing Address - Country:US
Mailing Address - Phone:715-526-4700
Mailing Address - Fax:
Practice Address - Street 1:1291 RIVER VALLEY RD
Practice Address - Street 2:
Practice Address - City:SOBIESKI
Practice Address - State:WI
Practice Address - Zip Code:54171-9413
Practice Address - Country:US
Practice Address - Phone:920-309-1719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-18
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8388-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional