Provider Demographics
NPI:1912116617
Name:ELLIOTT, THOMAS BRICE (PHD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:BRICE
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 1ST ST
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-4601
Mailing Address - Country:US
Mailing Address - Phone:951-544-1146
Mailing Address - Fax:909-793-5444
Practice Address - Street 1:47 1ST ST
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4601
Practice Address - Country:US
Practice Address - Phone:951-544-1146
Practice Address - Fax:909-793-5444
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 4292103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PL42920Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER