Provider Demographics
NPI:1780350397
Name:ELLIOTT, MYISHA ANTOINETTE
Entity type:Individual
Prefix:
First Name:MYISHA
Middle Name:ANTOINETTE
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 E CENTRAL AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-3344
Mailing Address - Country:US
Mailing Address - Phone:316-807-6879
Mailing Address - Fax:
Practice Address - Street 1:2501 E CENTRAL AVE STE 2
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-3344
Practice Address - Country:US
Practice Address - Phone:316-807-6879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-23
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS12151-T104100000X
KS12845104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker