Provider Demographics
NPI:1104450436
Name:ELLIOTT, EMILY JANE
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:JANE
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 1:8767 CARMEL VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:CA
Mailing Address - Zip Code:93923-7958
Mailing Address - Country:US
Mailing Address - Phone:831-582-1017
Mailing Address - Fax:
Practice Address - Street 1:8767 CARMEL VALLEY RD
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:CA
Practice Address - Zip Code:93923-7958
Practice Address - Country:US
Practice Address - Phone:831-582-1017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-25
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1669934261Medicaid