1174196166 NPI number — MS. KAETE LOUISE ELLIOTT M.A.,M.DIV.

Table of content: MS. KAETE LOUISE ELLIOTT M.A.,M.DIV. (NPI 1174196166)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174196166 NPI number — MS. KAETE LOUISE ELLIOTT M.A.,M.DIV.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLIOTT
Provider First Name:
KAETE
Provider Middle Name:
LOUISE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
M.A.,M.DIV.
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:
1174196166
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
417 SAN FRANCISCO AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POMONA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91767-4733
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-533-7004
Provider Business Mailing Address Fax Number:
626-403-5950

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1910 HUNTINGTON DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH PASADENA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91030-4886
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-403-5950
Provider Business Practice Location Address Fax Number:
626-540-3595
Provider Enumeration Date:
07/19/2021

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: 106H00000X , with the licence number:  32179 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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