1598876757 NPI number — MRS. MELISSA L ELLIOTT M ED LMFT

Table of content: MRS. MELISSA L ELLIOTT M ED LMFT (NPI 1598876757)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598876757 NPI number — MRS. MELISSA L ELLIOTT M ED LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLIOTT
Provider First Name:
MELISSA
Provider Middle Name:
L
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M ED LMFT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598876757
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
605 VIGO CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROLESVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27571-9340
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-761-9446
Provider Business Mailing Address Fax Number:
919-761-9446

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
149 CAMPUS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WARRENTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27589-8601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-306-4815
Provider Business Practice Location Address Fax Number:
919-761-9446
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  675 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YP2500X , with the licence number: 675 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 13846 . This is a "NC HEALTH CHOICE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 6105048 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8376 . This is a "FIVE COUNTY MENTAL HEALTH" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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